• More U.S. Women Dying From Childbirth. How One State Bucks the Trend. (Michael Ollove, Stateline, Pew Trust, 10-23-18) "Over the past three decades, the world has seen a steady decline in the number of women dying from childbirth. There’s been a notable outlier: the United States. Here the maternal mortality rate has been climbing, putting the United States in the unenviable company of Afghanistan, Lesotho and Swaziland as countries with rising rates. But that trend has been reversed in dramatic fashion in one state: California. The state Department of Public Health calculates that between 2006 and 2013, California lowered its maternal mortality rate by 55 percent from 16.9 to 7.3 deaths for every 100,000 live births...California has made a difference in part by focusing narrowly on problems that arise during labor and delivery, using data collection to quickly identify deficiencies (such as failing to have the right supplies on hand or performing unnecessary C-sections) and training nurses and doctors to overcome them."
• Your Biggest C-Section Risk May Be Your Hospital (Tara Haelle, Consumer Reports, 5-10-18) Consumer Reports finds that your odds of having a c-section can be over nine times higher if you pick the wrong hospital...this study shows that it is possible for women, if properly armed with data, to vote with their feet and send a signal to the medical community by choosing—if possible—a hospital with a lower C-section rate,” explains Doris Peter, Ph.D., former director of the Consumer Reports Health Ratings Center...According to a recent consensus statement by the American College of Obstetricians and Gynecologists (ACOG), there are about four deaths for every 100,000 women after vaginal deliveries and about 13 deaths for every 100,000 women after cesareans....And you don’t just get the freedom to choose a doctor or practice you like. Because doctors are only credentialed to work in certain hospitals, you have to know where you want to deliver as much as which group you want to see."
• Data shines a light on C-sections, maternal mortality (Brenda Goodman, Covering Health, AHCJ, 5-13-14)
• The Age That Women Have Babies: How a Gap Divides America (Quoctrung Bui and Claire Cain Miller, NY Times, 8-4-18) "The difference in when women start families cuts along many of the same lines that divide the country in other ways, and the biggest one is education. Women with college degrees have children an average of seven years later than those without — and often use the years in between to finish school and build their careers and incomes....Researchers say the differences in when women start families are a symptom of the nation's inequality -- and as moving up the economic ladder has become harder, mothers' circumstances could have a bigger effect on their children’s futures."
• Iowa Lawmakers Pass Abortion Bill With Roe v. Wade in Sights (Julie Bosman and Mitch Smith, NY Times, 5-2-18) Republicans pressing the Iowa legislation are making a decisive turn away from the smaller, more incremental measures of the past that have, in their view, merely chipped away at abortion rights. They have a new, longer-term goal in their sights: reaching a Supreme Court that could shift in composition with a Republican president in the White House, potentially giving the anti-abortion movement a court more sympathetic to its goal of overturning Roe v. Wade than the current court is....The Iowa Legislature approved what would be the nation’s strictest abortion law in an early-morning vote on Wednesday. The move intended to pose an aggressive challenge to Roe v. Wade and reignite conservative energy before the midterm elections in November.
• Cartoon about birth control, abortion, and the welfare state (Joel Pett and the Cartoonist Group, on Kaiser Health News, 11-12-18)
• Roe v. Wade, Part 1: Who Was Jane Roe? (Audio only, The Daily, NY Times, 7-23-18) "We examine how abortion--and the Supreme Court case that legalized the procedure in the United States--became one of the most politically divisive issues of our time."
• The Future of Roe v. Wade: 3 Scenarios, Explained (video, Adam Liptak explains, with reporting by Robin Stein, Aaron Byrd, Natalie Reneau, Anjali Singhvi, and Jonah M. Kessel, NY Times, 8-10-18) Will a Supreme Court with two Trump-appointed justices overrule the right to an abortion? It's possible, but not the most likely outcome. The three options: the nuclear option, overrule Roe, chip away at Roe. It's unlikely to go after the right to privacy.
• The Health Department’s Christian Crusade (Tessa Stuart, Rolling Stone, 10-24-18) The religious right has infiltrated the office of Health and Human Services, and reproductive rights are the first target
• “Whatever’s your darkest question, you can ask me.” (Lizzie Presser, California Magazine, 3-28-18) Anna became interested in home birth and home abortion after having been poorly treated in a hospital. In Anna’s view and that of many legal scholars, Roe upheld a doctor’s right to perform an abortion, not a woman’s right to choose one. Choice wasn’t just whether a woman could seek an abortion but also how and when she wanted to have it, who she wanted around her, and where she wanted to be.
• Where Did Ireland Go? Abortion Vote Stuns Those on Both Sides (Kimiko de Freytas-Tamura, NY Times, 5-27-18) 'There are many factors behind Ireland’s dramatic makeover. The most dominant reason is the collapse of the Catholic Church’s influence in most spheres of Irish life. “It’s very important to know that Ireland has been secularizing for a long time,” said Diane Negra, a professor of cultural studies at University College Dublin. The credibility of the church has been battered by a string of scandals, some involving pedophile priests and the cover-up of their crimes. Ireland’s practice of placing thousands of unwed mothers into servitude in so-called Magdalene laundries, designed to rehabilitate what the church considered “fallen” women, did not end until the mid-1990s. And in a case that traumatized the nation, the remains of nearly 800 children born out of wedlock were found in 2014 in a Catholic-run home for mothers and their children in Tuam....The referendum on abortion, many Irish said, was the final crack in the foundation of the old Ireland.'
• Should Abortion Be Legal? (ProCon.org, which covers many issues)
• Self-Induced Abortions Shouldn't Be A Crime, Mass. Medical Society Says (Chelsea Conaboy and Carey Goldberg, CommonHealth, WBUR, 5-7-18) At its latest meeting, the Massachusetts Medical Society took a new stand: Women who attempt to end a pregnancy on their own should not be considered criminals. Self-induced abortion is explicitly banned in seven states, and more have laws on the books that could be used to prosecute women for self-induction, according to a recent report....In many countries, the pills are available at pharmacies and even over the counter. Websites like Women Help Women offer support and send abortion pills by mail to women around the world who wish to end an early pregnancy. But not in the U.S., where mifepristone is highly regulated despite its proven safety. It may be dispensed only in a clinical context by a prescriber who has obtained a special certification from the drug distributor. It is not available from retail pharmacies. “There are a lot of women who, for various reasons — including stigma, or just financial or geographic lack of access to care — are really attempting their own abortion.”
Let's not go back to the deadly era of abortion by coat hanger!
• Should Abortion Be Legal? (ProCon.org) Top pro and con arguments.
• Why the Abortion Fight Is Becoming a Battle Over Health Information (Chelsea Conaboy, CommonHealth, WBUR, 5-22-18) Abortion pills -- typically a combination of misoprostol and mifepristone, the same drugs used in medication abortions initiated at a clinic -- are widely available for sale from online pharmacies. That’s reassuring to people who support abortion rights, as President Trump works to make good on a promise to “defund” Planned Parenthood, and as emboldened conservative governors race to pass restrictive state laws, with a legal challenge to Roe v. Wade in mind. But it also raises the stakes for women, if the call to punish those who self-induce abortion grows louder. And it puts a sharp focus on why the battle over abortion increasingly is a battle over health information, because an informed woman can gain access to abortion drugs via the Internet no matter how far she lives from a clinic....
"Abortion access is fundamentally different than it was 30 years ago, in at least one significant way: Women today have access to safe, private, do-it-yourself abortion -- if they know where to look. Or rather, which search terms to type into Google."
• What Does Trump's Proposal To Cut Planned Parenthood Funds Mean?
• The Abortion Pill (Planned Parenthood) Medication abortion — also called the abortion pill — is a safe and effective way to end an early pregnancy.
• Clinics That Refer Women for Abortions Would Not Get Federal Funds Under New Rule (Sarah McCammon and Scott Neuman, WBUR News, 5-18-18)
• Women Help Women
• Plan C

• Pain (MedlinePlus)
• Words Matter When Talking About Pain With Your Doctor (Patti Neighmond, Shots, Morning Edition, NPR, 7-23-18) Rating pain on a numerical scale (1 to 10) may be too simplistic. "Treating by numbers" may not get patients the most effective treatment for their particular pain. For chronic pain, being clear can help clinicians choose the right mix of therapies or medications to allow you to stay as active as possible. And staying active can help manage chronic pain. A few alternatives. "Jeter typically asks patients to compare their current pain to the worst pain they ever had, such as childbirth or kidney stones."
• See full separate section on Managing chronic pain
• A comprehensive guide to the new science of treating lower back pain (Julia Belluz, Show Me the Evidence series, Vox, 12-12-17) A review of 80-plus studies upends the conventional wisdom. Did you know that "Moving is probably the most important thing you can do for back pain"? or why exercise is helpful? What about spinal manipulation by chiropractors? massage? acupuncture? And which medications might help without causing addiction? Study up--a good overview.
• Crooked: Outwitting the Back Pain Industry and Getting on the Road to Recovery by Cathryn Jakobson Ramin
• Pain Relievers: Understanding Your OTC Options (FamilyDoctor.org)
• Pain Relief: What You Need to Know (Consumer Reports, 4-28-16) 125 million people are in pain, spending some $300 billion on pills, pot, procedures, and natural ‘cures’ to find relief, but are they worth it?
• Pain Management: Which Treatment Is Right for You? (Consumer Reports, 4-28-16)
• You’re wrong. Pain is not a vital sign. (Miles Gart, KevinMD, 5-15-17) Vital signs are clinical measurements, specifically: pulse rate, temperature, respiration rate and blood pressure, that indicate the state of a patient’s essential body functions. After years of exaggeration, misinformation and a national epidemic of opioid and heroin abuse, the nation is finally coming to terms with the fact that pain is not the fifth vital sign. As a result of equating pain as a vital sign, medical practitioners must come up with a reliable and effective treatment if and when a patient subjectively rates their pain high on the scale.
• Addictive Pain Medication: How to Protect Yourself (Theresa Carr, CR, 4-28-16) Many painkillers can be highly addictive
• Try This Instead of Drugs to Treat Neck and Shoulder Pain (CR, 4-28-16) Strengthening weak neck muscles with exercise and applying heat can alleviate the pain
• How to Get Rid of Lower Back Pain (Consumer Reports, 4-28-16) If you don't feel better after four weeks, see a doctor because it could be another condition, like osteoporosis
• Best Ways to Treat Joint Pain (CR, 4-28-16) Stiff or swollen joints can result in pain, especially first thing in the morning and after resting. Here's what you can do to ease it.
• Is Supercooling the Body an Effective Therapy? (Dina Fine Maron, Scientific American, 10-31-16) The market for cryotherapy "devices is beginning to burgeon in the U.S., with sports teams snapping them up to condition their players, and spas and wellness centers installing them for clients looking to relax, lose weight and fight signs of aging....Yet the science behind these devices is decidedly lackluster. In July the U.S. Food and Drug Administration issued a warning stating that there is no evidence these technologies help to ease muscle aches, insomnia or anxiety or provide any other medical benefit. Instead, it said, they may cause frostbite, burns, eye damage or even asphyxiation. In a statement to Scientific American the agency added, 'The FDA has not approved or cleared any whole-body cryotherapy devices, and we do not have the necessary evidence to substantiate any medical claims being made for these devices.'”
• Acetaminophen Is the Best Pain Reliever for Heart Patients (Orly Avitzur, Consumer Reports, 6-19-16) "Tylenol is a good choice for those needing relief from the physical pain caused by osteoarthritis in the joints or from headache pain and who also have heart troubles such as high blood pressure, heart failure, heart attacks, chest pain due to narrowed coronary arteries (angina), or stroke. Using acetaminophen is a much safer bet than most over-the-counter pain relievers like ibuprofen (Advil and generic) and naproxen (Aleve and generic)....That’s because acetaminophen is unlike other common, over-the-counter pain medications, like ibuprofen and naproxen, which can aggravate high blood pressure, and in turn raise a person's risk of having a heart attack. "
• Tension Headache Treatment and Prevention (CR, 4-28-16) A few simple steps like drinking water and doing neck exercises can relieve your pain
• Speak Up: What You Should Know about Pain Management (Joint Commission)
• Chronic Pain Medicines (FamilyDoctor.org).
• When Pain Remains (Jerome Groopman, New Yorker, 10-10-05) What should patients do when doctors can't figure out how to diagnose or treat reflex sympathetic dystrophy (RSD), reclassified in 1994 as complex regional pain syndrome (CRPS), the hallmark of which is excruciating pain.
• When Pain Remains: Q & A (sidebar to the Groopman piece on CRPS). What should patients do when doctors can’t figure out how to treat their suffering?
• How OxyContin's Pain Relief Built 'A World Of Hurt' WHYY's Fresh Air interviews Barry Meier, author of A World of Hurt: Fixing Pain Medicine's Biggest Mistake (Kindle single)
• Neuroplastix Change the Brain; Relieve the Pain; Transform the Person. Read the book free online.
• The disturbing reason some African American patients may be undertreated for pain (Sandhya Somashekhar, Wash Post) African Americans are routinely under-treated for their pain compared with whites, according to research. Whites are more likely than blacks to be prescribed strong pain medications for equivalent ailments. Unconscious stereotypes about African Americans likely contribute to this problem, as well as physicians' difficulty empathizing with patients whose experiences differ from theirs.
• Ways to Reduce Pain Naturally
• Who Has a Right to Pain Relief? (Rebecca Davis O'Brien, The Atlantic, 8-18-14). The legal, medical, and pharmaceutical industries have all struggled to locate the line between analgesia and drug abuse.
• Keith Wailoo on the politicization of pain (Book TV, C-Span, 3-3-15) Professor Keith Wailoo talked about his book, Pain: A Political History, about the politicization of treating pain in the U.S. since the 1950s. How do we decide who is or is not (really) in pain and how to treat that pain. Is chronic pain a disability that should be compensated? Are we exercising compassion in treating pain or creating a generation of dependents. It's the judges, not the doctors and not the scientists, who make significant decisions about pain. (Listen, watch, or read transcript.)
• Pain: A Political History by Keith Wailoo. A "well-rounded discussion of the politics of pain and pain relief in post WW II America." Wailoo examines how pain has defined the line between liberals and conservatives from just after World War II to the present. From disabling pain to end-of-life pain to fetal pain, the battle over whose pain is real and whose pain deserves relief has created stark ideological divisions at the bedside, in politics, and in the courts -- and the interests and arguments of media, politicians, and medical professionals often work against the voice of the individual suffering pain. What about managing pain in end-of-life care?
• Kratom Users Say Ban Will Lead to More Drug Abuse (Pat Anson, Pain News Network, 9-20-16) Kratom is a safe and surprisingly effective treatment for chronic pain and a wide variety of medical conditions, according to a large new survey of kratom consumers. Many say banning the herbal supplement will only lead to more drug abuse and worsen the nation’s opioid epidemic. (An online survey of 6,150 kratom consumers by Pain News Network and the American Kratom Association was conducted after plans were announced by the U.S. Drug Enforcement Administration to classify two chemicals in kratom as a Schedule I controlled substances.)
• Why Banning the Controversial Painkiller Kratom Could Be Bad News for America's Heroin Addicts (Maia Szalavitz, Vice, 1-20-16) "It sounds like the perfect drug. At low doses, it's stimulating, like a strong cup of coffee; at higher doses, it's sedating and kills pain. And it's a legal, natural plant that has been used in Asian medicine for centuries. Indeed, a growing number of Americans are finding it to be a useful alternative to heroin and prescription pain relievers. But of course, there's a catch. Like the opioid drugs it is used to replace, this stuff can be addictive, and it can also cause serious nausea. Unlike other opioids, however, it seems to have an extremely low overdose risk, which has caught the eye of people working to fight the record high level of overdose deaths."

• Beyond pills and shots: Pain patients seek other options (Felice J. Freyer, Boston Globe, 12-30-16). Part of an invaluable series, specific titles for which can be found here (read 5-piece limit for free): Boston Globe series on chronic pain. See, for example, Doctors are cutting opioids, even if it harms patients (Freyer, 1-3-17) as well as other stories on opioids, and When Chronic Pain Is a Child's Companion, among several important stories.
• Treating pain in older adults takes more than painkillers (Michele Munz, St. Louis Post-Dispatch, 5-9-17) About 50% of older adults living on their own and 75% to 85% of those in care facilities suffer from chronic or persistent pain. Pain goes largely untreated in this population because many assume it’s a natural part of aging and don’t know it can be treated, experts say, or they believe it will lead to expensive tests or more medications. Pain management in older adults has to extend beyond painkillers, writes Munz. That's where integrative medicine comes in.
• Beyond pills and shots: Pain patients seek other options (Felice J. Freyer, Boston Globe, 12-30-16). Part of a series on chronic pain.
• What is TN? (Facial Pain Association). "Trigeminal neuralgia (TN) is considered to be one of the most painful afflictions known to medical practice. TN is a disorder of the fifth cranial (trigeminal) nerve. The typical or “classic” form of the disorder (called TN1) causes extreme, sporadic, sudden burning or shock-like facial pain in the areas of the face where the branches of the nerve are distributed – lips, eyes, nose, scalp, forehead, upper jaw, and lower jaw. The pain episodes last from a few seconds to as long as two minutes. These attacks can occur in quick succession or in volleys lasting as long as two hours. The “atypical” form of the disorder (called TN2), is characterized by constant aching, burning, stabbing pain of somewhat lower intensity than TN1. Both forms of pain may occur in the same person, sometimes at the same time."
• How a Crazy Old French Woman Cured My Chronic Back Pain — and Healed My Soul (Abigail Rasminsky, Lenny, 1-19-18). Listen to it being read aloud on Restoration Row and, starting at minute 16, listen to a Q&A with Abby. From the article: 'I thought I’d never escape the shackles of back pain. All it took was throwing away everything I thought I knew about my body...."The secret to this pain-free posture? The pelvis had to be tilted forward, or, in yoga parlance, un-tucked. In regular-people lingo: the butt had to stick out. From this base, the spine could elongate up naturally. Any pain caused by a herniated disk would be alleviated with this freed-up space between the vertebrae." (Also by my goddaughter:) Dance Me to the End of Love (Abigail Rasminsky, Longreads, 1-8-18) "It was a small moment — an ordinary moment. Pain. We felt it all the time. But this was more: sharper, crippling — an ax slammed into my lower back." A young professional dancer keeps dancing through the pain, as so many dancers do. A story about dance, injury, chronic pain, and identity. "Anyone who has lived with chronic pain, however, knows how impossible it is to ignore your body. To live in pain is to live with the terrorizing feeling that you cannot get out of your body. That no matter where you go, or what you do, you will never outrun the pain, it will follow you everywhere — to dinner, to the movies, to work, to bed, into all your relationships, into the next day and the next and the next. You can distract yourself with friends or booze or TV, but that only works for a short time, if at all. It is the sensation of not being able to escape that is so unbearable." An earlier piece on the same woman/​process: I'm Off to See the Wizard.
• Pain for Women, Pain for Men (Proto magazine, Massachusetts General Hospital, Clinical Research, 8-10-17) Males and females experience pain differently—and appear to process it differently, too. Why has it taken so long for science to find out?
• Chronic Pain Patients Angry Over ‘Opioid Contracts’ (Shawn Radcliffe, Healthline, 5-2-18) More patients with chronic pain are being asked to agree to random urine drug screens, pill counts, and other conditions before they’re prescribed opioids. Many concerns, little evidence that the contracts are effective.
• 6 Ways to Take Control of Your Pain (Judy Foreman, AARP, Feb/​March 2015) Are you one of the 100 million Americans who suffer from chronic pain? Breakthrough research and innovative treatments offer hope. Strategy 1: Don't let the pain start. 2: Figure out exactly what type of pain you have. 3: Know that it's real. 4: Treat it right away. 5: Try non-drug treatments first. 6: Take the right drugs for your pain.
• Opioids and Paternalism (David Brown, American Scholar, Autumn 2017) "If the use of opioids for chronic pain were just making the practice of medicine less rewarding, the problem would be tolerable. But it’s changing the country, creating a new underclass in the United States, no less real (or less fraught with the potential for controversy) than the black underclass whose existence has been so central to American history of the past half century. The new underclass, mostly white, is distributed widely, with hot spots—Appalachia, rural New England, and surprisingly, far-northern California. Like those in the black underclass, members of the new underclass usually have no more than a high school education and suffer high unemployment....For some patients with chronic pain, opioids are the answer. But for most, treatment must begin with the doctor saying no. This needn’t be done callously, and people in pain don’t have to be left with nothing. Many things help a little—nonnarcotic drugs, acupuncture, transcutaneous electrical nerve stimulation (TENS), yoga, massage, exercise. Time and sympathy from a doctor, nurse, therapist, or coach are just as important as any of these treatments. The journey back from opioid drugs—or through the land of chronic pain without them—should not be taken alone."
• Vox reporter describes deep dive into medical studies on back pain (Tara Haelle, Covering Health, AHCJ, 12-5-17) Two years ago Vox began a new feature section called Show Me the Evidence. In each piece, the reporter reviews several dozen recent studies on a specific question with the goal of summarizing the consensus of the evidence on that issue.
• A comprehensive guide to the new science of treating lower back pain (Julia Belluz, Vox, 8-4-17) A review of 80-plus studies upends the conventional wisdom. Part of Vox's Show Me the Evidence series. "Low back pain is the second most common cause of disability in the US, but the most popular treatments out there--spine surgery, opioid painkillers, stereoid injections--are unhelpful for most people , or even downright harmful. The exercise increasingly supports a range of exercise programs and alternative therapies, such as massage and yoga, that can help people alleviate" the soreness in their backs.
• Crooked: Outwitting the Back Pain Industry and Getting on the Road to Recovery by Cathryn Jakobson Ramin. Jakobson Ramin shatters assumptions about surgery, chiropractic methods, physical therapy, spinal injections, and painkillers, and addresses evidence-based rehabilitation options—showing, in detail, how to avoid therapeutic dead ends, while saving money, time, and considerable anguish. Listen to Cathryn Jakobson Ramin on the ‘Crooked’ Back Pain Industry (Eric Westervelt interviews Ramin on Forum, KQED, 5-22-17). She pulls back the curtain on the back pain industry and provides strategies for navigating the plethora of treatment options. Exercise very important (strengthen the weak muscles, stretch the tight muscles, as one caller puts it) . Long-term visits to chiropractors aren't the answer (one or two sessions could be helpful but let them nowhere near your neck). You need well-developed glutes and thighs. Yoga, yes, but not competitive yoga, where you are pushed to do more than you are capable of doing; you want a many-years-experienced yoga teacher (not just someone who is "certified"): she recommends Iyengar and Viniyoga Practice. See Ramin's guide to resources.
• Sickle Cell Patients Suffer Discrimination, Poor Care — And Shorter Lives (Jenny Gold, KHN, 11-6-17) About 100,000 people in the United States have sickle cell disease, and most of them are African-American. In 1994, life expectancy for sickle cell patients was 42 for men and 48 for women. By 2005, life expectancy had dipped to 38 for men and 42 for women. Sickle cell disease is “a microcosm of how issues of race, ethnicity and identity come into conflict with issues of health care,” said Keith Wailoo, a professor at Princeton University, and author of Sickle Cell Disease — A History of Progress and Peril (Keith Wailoo, New England Journal of Medicine, 3-2-17) Studies have found that sickle cell patients have to wait up to 50 percent longer for help in the emergency department than other pain patients. The opioid crisis has made things even worse, Vichinsky added, as patients in terrible pain are likely to be seen as drug seekers with addiction problems rather than patients in need.
• Home remedies for alleviating sciatica pain (McNees blog, 4-2-16) The piriformis muscle is a small muscle located deep in the buttock (behind the gluteus maximus). It starts at the lower spine and connects to the upper surface of each femur (thighbone). It helps to rotate the hip and turn the leg and foot outward. It sits under deep layers of fat and muscle in your buttock, so if you sit a lot and don't move around, those muscles get compressed. Get up from that chair and move around more! Meanwhile, here are some suggested remedies.
• Dr. John Sarno on healing lower mid-back pain, sciatica, psoas pain ' (20/​20 segment, YouTube). (Basically, "It's all in your head." -- that is, he says that's often true AFTER you have ruled out physical problems. Your brain protects you from negative emotions by referring them to your back.). Or read his book: Healing Back Pain: The Mind-Body Connection. A lot of people seem to have been helped by this book. Goodreads: " John Sarno, MD, at the NYU School of Medicine discovered in the 1970s that back pain was not coming from the things seen on the imaging, such as herniated discs, arthritis, stenosis, scoliosis, etc. Pain was coming from oxygen reduction through the autonomic nervous system due to elevated tension levels, but had been errantly linked to the "normal abnormalities" seen on MRIs and X-rays. Most physicians refused to believe his findings even though his success rate in healing the most troublesome of pain-cases was well above theirs. Dr. Sarno labeled the disorder TMS, or tension myoneural syndrome, currently being called The Mindbody Syndrome." (From a review of Hanscom's book, below).
• How well-intentioned doctors helped create the opioid epidemic (The Impact, Vox, 11-7-17) The policies that created the opioid epidemic.
• Opioids often aren't a great way to treat chronic pain. So … what is? ( The Impact, Vox, 11-13-17) A doctor, Jane Ballantyne, helps her chronic pain patients with pain acceptance; a chronic pain patient named Kristin Geiger has embraced pain acceptance — and is actually trying to wean herself off of opioids right now; and a patient named Sam Merrill is really skeptical that he can replace his opioid prescription with physical therapy and meditation — or “just live” with his crippling pain. A pain patient weaning herself off opioids, a pain patient who can't imagine his life without them, and the future of pain treatment.
• Healthcare Hashtag Project, a free open platform for patients, caregivers, advocates, doctors and other providers that connects them to relevant conversations and communities. Thousands of patients talk about diseases weekly in "chats" on Twitter.
• Giving Chronic Pain a Medical Platform of Its Own (Tara Parker-Pope, Well, NY Times, 7-18-11) What doctors don't know about chronic pain. “Having pain that is not treated is like having diabetes that’s not treated,” said Ms. Thernstrom, who suffers from spinal stenosis and a form of arthritis in the neck. “It gets worse over time.”
• New Pathways to Overcome Chronic Back Pain (listen to podcast of back surgeon David Hanscom, author of Back in Control: A spine surgeon's roadmap out of chronic pain, on Show 972 of "The People's Pharmacy"). "According to Dr. David Hanscom, a leading spine surgeon, back pain can be overcome, but surgery is frequently NOT the best choice. People with chronic back pain may need to overcome their anger and anxiety and use an integrated approach to build new neural pathways that circumvent the pain. Some of the best tactics include finding a way to play as well as a way to confront anger and find forgiveness." From Goodreads: "Steve tells his compelling story of a 30-year battle with pain and ultimate healing after discovering Dr. Sarno's work. After Steve healed he began receiving hundreds of emails, calls, and letters, asking for his help--too many to respond to, so he decided to write his experience down in a book." See the Goodreads comments on book."This is a more readable book than Sarno's, says one reader.
• Hurting All Over (Jerome Groopman, New Yorker, 11-13-2000) With so many people in so much pain, how could fibromyalgia not be a disease?
• Biofeedback: A High-Tech Weapon Against Migraines (Sue Russell, Healthymagination 7-18-11)
• Migraine Treatment, Prevention & Relief (CR, 4-28-16) Tips on how to treat—and even prevent—this common type of pain
• Chronic Lyme and other tick-born diseases ("When the doctor gets sick, the journey is double-edged," by Pamela Weintraub, Psychology Today, in 3 parts)
• Pains (Janice Lynne Schuster and the Pain Project). Many articles, including
--An Unwelcome Guest: Living with Chronic Pain (Schuster, Disruptive Women in Health Care, 12-15-14)
--Draft of the National Pain Strategy has been published to the Federal Register (PAINS Project, 4-2-15) the National Institute of Neurological Disorders and Stroke (NINDS) Office of Pain Policy today published a notice soliciting public comment on the draft National Pain Strategy.
--In pain? (Some resources. Janice Lynne Schuster's site.)
• Complex regional pain syndrome (CRPS, Mayo Clinic staff)
• Complex Regional Pain Syndrome fact sheet (National Institute of Neurological Disorders and Stroke
• Chronic back pain
• Dancing with Pain (one approach to pain relief)
• For Grace. Resources for Women in Pain.
• How to Cope with Pain website (breathing and relaxation exercises, guided imagery,etc.--includes favorite how-to-cope-with-pain submissions
• Living With Pain That Just Won’t Go Away (Jane E. Brody, NY Times, 11-6-07)
• Quality of Life Scale , a measure of function for people with pain (pdf, American Chronic Pain Association)
• The Pain Chronicles: Cures, Myths, Mysteries, Prayers, Diaries, Brain Scans, Healing, and the Science of Suffering by Melanie Thernstrom
• The Permanent Pain Cure: The Breakthrough Way to Heal Your Muscle and Joint Pain for Good by Ming Chew with Stephanie Golden
• Reflex Sympathetic Dystrophy Syndrome Association (RSDSA), promotes public and professional awareness of Complex Regional Pain Syndrome (CRPS), also known as Reflex Sympathetic Dystrophy (RSD)
• The Psychology of Pain: It’s Not What You Think (Stan Goldberg's interesting and informative essay)
• Chronic pain not only hurts, it also causes isolation and depression. But there’s hope. (Rachel Noble Benner, Wash Post, 1-12-15)
• One in 3 women could potentially be spared chronic pain after breast cancer surgery (Medical Press, 2-25-15)
• Here’s What’s Wrong With How US Doctors Respond to Painkiller Misuse(Maia Szalavitz, Substance.com, 1-13-15).
• New Report Details Uphill Battle to Solve the U.S.'s Pain Problem (Bob Roehr, Scientific American, 7-1-11) The Institute of Medicine reveals a "blueprint" for relieving Americans' pervasive chronic pain.
• Opioid Misuse In Chronic Pain Patients Is Around 25%, New Study Shows (CJ Arlotta, Forbes, 4-1-15)
• Opioids: addiction, overdose, treatment, and recovery (addiction to heroin, cocaine, crack, and other illegal and addictive painkillers--and addictive prescription drugs) In section on Substance Abuse.
• Culprits in the opioid crisis. In section on Substance Abuse.
• Opioid addiction treatment with a dark side In section on Substance Abuse.
• Overdoses (and reversing overdoses) In section on Substance Abuse.
• Managing ordinary (not chronic) pain

• The Health Effects of Cannabis and Cannabinoids: The Current State of Evidence and Recommendations for Research (press release, National Academies of Sciences, Engineering, and Medicine, 1-12-17) A once-over-lightly summary of what the evidence supports (ranging from their therapeutic effects to their risks for causing certain cancers, diseases, mental health disorders, and injuries). Scroll down to download the report itself (free).
• DCRx: The DC Center for Rational Prescribing runs a Continuing Medical Education program on Medical Cannabis for Pain, among other topics, with excellent resources online, including slides and video of presentations, Q&A etc. There is an option to click for non-CME access for the general public.
• The Medical Use of Marijuana v. The Use of Marijuana for Medical Purposes (Bradley Steinman, American Bar Association)
• Cannabis for Elders: A Precarious State (Liana Aghajanian, The Atlantic, 7-22-13)
• The Complete Guide to Medical Marijuana for Elders (National Council for Aging Care)
• My Personal Experiences with the Medical Marijuana Business and the Opioid Epidemic (David Meerman Scott, Healthcare in America, 1-4-17) Marijuana is a safer alternative to opioids for pain relief, but you have to jump through hoops to qualify for medical marijuana. A business story that may prove helpful.
• Weed (Sanjay Gupta's documentary on medical marijuana)
• Marijuana stops child's severe seizures (Saundra Young, CNN, 8-7-13) Much good background information.
• To Save Her Daughter, This Mom Became a Medical Marijuana Pioneer On a Facebook group of parents across the world with children with an incurable genetic disorder called CDKL5, one mother in the U.S. described giving her daughter cannabis-based medicines to mitigate the epileptic fits that are a symptom of the disorder. After figuring out the practical aspects of using such medicine for her daughter's condition, a mother in Brazil took on Brazil’s tangled legal system to become the first person in the country’s history with permission to grow cannabis for medicinal purposes. Other Brazilians, mostly parents of children with degenerative diseases, are forced to seek out expensive medical marijuana in clandestine fashion, risking punitive jail sentences if they are caught. The NGO Support for Patients and Research for Medicinal Marijuana (APEPI) pushes for advances in legalization and research permissions.
• Medical marijuana (Mayo Clinic) Despite a federal ban, many states allow use of medical marijuana to treat pain, nausea and other symptoms. Is medical marijuana legal under federal law in the U.S.? When is medical marijuana appropriate?
• Marijuana as Medicine (Drug Facts, National Institute on Drug Abuse, April 2017) The term medical marijuana refers to using the whole, unprocessed marijuana plant or its basic extracts to treat symptoms of illness and other conditions. The U.S. Food and Drug Administration (FDA) has not recognized or approved the marijuana plant as medicine. However, scientific study of the chemicals in marijuana, called cannabinoids, has led to two FDA-approved medications that contain cannabinoid chemicals in pill form. Continued research may lead to more medications. Because the marijuana plant contains chemicals that may help treat a range of illnesses and symptoms, many people argue that it should be legal for medical purposes. In fact, a growing number of states have legalized marijuana for medical use.
• News about Marijuana and Medical Marijuana, including commentary and archival articles published in The New York TimesRESEARCH ON MEDICAL MARIJUANA
• Many links here were posted as background Stories from the panel "Medical ramifications of legal marijuana", from a conference of the Association of Health Care Journalists (accessible only to members). As one member stated, "It's important to differentiate between oral THC, which is an FDA approved medication (dronabinol), and 'medical marijuana,' which if you're talking Colorado-style is just the smoked plant."
• Taking a science-informed approach to medical marijuana (Nora D. Volkow, director of the National Institute on Drug Abuse, Alcoholism & Drug Abuse Weekly, 4-27-15) "There is solid evidence that the main psychoactive ingredient in marijuana, THC, is effective at controlling nausea and boosting appetite. There is also some preliminary evidence that THC or related cannabinoid compounds such as cannabidiol (CBD) may also have uses in treating autoimmune diseases, inflammation, pain, seizures and psychiatric disorders, including substance use disorders. Despite claims of marijuana’s usefulness in treating post-traumatic stress disorder, supporting data is minimal, and studies have not investigated whether symptoms may worsen after treatment is discontinued." There is less support for some other claims of marijuana's health benefits, and "As public approval for medical marijuana grows, we need to ensure that our policy decisions are science-based and not swayed by the enthusiastic claims made widely in the media or on the Internet."
• Gupta: 'I am doubling down' on medical marijuana (Sanjay Gupta, CNN, 3-6-14) Apologizing for having previously spoken against marijuana use, Gupta writes about "emerging science that not only shows and proves what marijuana can do for the body but provides better insights into the mechanisms of marijuana in the brain, helping us better understand a plant whose benefits have been documented for thousands of years. This journey is also about a Draconian system where politics overrides science and patients are caught in the middle."
• Weed (Sanjay Gupta's documentary on medical marijuana)
• America's Weed Rush , an investigation of marijuana legalization in America, is the 2015 project of the Carnegie-Knight News21 program, a national multimedia investigative reporting project produced by the nation’s top journalism students and graduates. 27 journalism students from 19 universities traveled through half the country to report on the politics, regulation and science behind the nation’s marijuana movement. Topics addressed: The science: Is marijuana safe? Medical marijuana: the demand for it.. Recreational marijuana--the push to regulate it. Money: the business and the complications therefrom. Law enforcement: How marijuana is pushing the limits of legality. Marijuana politics: Critics call legalization of marijuana out of control.
• Center for Medical Cannabis Research (CMCR) (best academic resource on medical marijuana; established by the California legislature to answer the question "Does marijuana have therapeutic value? Run by Igor Grant
• California pot research backs therapeutic claims (Peter Hecht, Sacramento Bee, 7-12-12) Three years after California voters passed the nation's first medical marijuana law in 1996, the legislature in 1999 approved funding for the nation's first sustained modern medical research for pot. University of California medical researchers slipped an ingredient in chili peppers beneath the skin of marijuana smokers to see if pot could relieve acute pain. It could – at certain doses....State-funded studies – costing $8.7 million – found pot may offer broad benefits for pain from nerve damage from injuries, HIV, strokes and other conditions....Igor Grant said he worries about a lack of standardization for medical marijuana. He suggests people buying pot at dispensaries – offering products far more potent than used in state research – is akin "to going to a flea market for an antibiotic."
• Marijuana stops child's severe seizures (Saundra Young, CNN, 8-7-13) Good background information.
• Cannabis Science (My Chronic Relief) “Cannabis is the single most versatile herbal remedy, and the most useful plant on Earth. No other single plant contains as wide a range of medically active herbal constituents.”~Dr. Ethan Russo, Neurologist, Botanist and Cannabis Expert – Cannabinoid Research Institute (Google Russo's name for more stories)
• Cannabis for migraine treatment: the once and future prescription? An historical and scientific review (Ethan Russo, Pain, 1-26-98)
• No, legalizing medical marijuana doesn’t lead to crime, according to actual crime stats (Emily Badger, Washington Post, 3-26-14)
• Seniors and Pot (stories from The Cannabist, the Denver Post's website on all things pot, from laws to research to strains of weed))
• Suicide rates fall when states legalize medical marijuana, says new study ( Scot Kersgaard, Colorado Independent, 2-24-12)
• Why Medical Marijuana Laws Reduce Traffic Deaths (Maia Szalavitz, Time, 12-2-11)
• Efficacy and safety of medical cannabinoids in older subjects: a systematic review. (GA van den Elsen and others, Ageing Res Rev, Epub 2014 Feb 5) " The studies showed no efficacy on dyskinesia, breathlessness and chemotherapy induced nausea and vomiting. Two studies showed that THC might be useful in treatment of anorexia and behavioral symptoms in dementia. Adverse events were more common during cannabinoid treatment compared to the control treatment, and were most frequently sedation like symptoms. Although trials studying medical cannabinoids included older subjects, there is a lack of evidence of its use specifically in older patients. Adequately powered trials are needed to assess the efficacy and safety of cannabinoids in older subjects, as the potential symptomatic benefit is especially attractive in this age group." To access this and other articles about seniors and medical marijuana, see PubMed.
• Teen Marijuana Use May Show No Effect On Brain Tissue, Unlike Alcohol, Study Finds (Kathleen Miles, Washington Post, 12-23-12)
• Graduation rates up in Colorado, South High leads Denver school gains (Denver Post, 1-23-14)

SOURCES OF INFORMATION and REPORT CARDS ABOUT U.S. HOSPITALS
• Citizens for Patient Safety Links to relevant organizations around the country and other resources. "A conversation can change an outcome. A conversation can change a life."
• Dollars for Docs (Mike Tigas, Ryann Grochowski Jones, Charles Ornstein, and Lena Groeger, ProPublica, 6-28-18 and they do update) Pharmaceutical and medical device companies are required by law to release details of their payments to a variety of doctors and U.S. teaching hospitals for promotional talks, research and consulting, among other categories. Use this tool (Find surgeons and hospitals near your location) to search for general payments (excluding research and ownership interests) made from August 2013 to December 2016. Has your doctor received drug or device company money?
• Globe1234 (researcher Paul Burke's site, which summarizes information (mostly from Medicare) about doctors and hospitals. Worth exploring. If you click on an article--for example, Medicare's Challenging Relationship with Hospitals--along right side of page you can see links to other topics covered. See in particular Hospital Quality and Incentives and Doctors' Quality and Incentives .
• Health Grades (ratings for physicians)
• Guidestar (a major source of information on nonprofit organizations, including nonprofit hospitals)
• Health Watch USA (an invaluable resource: a nonprofit patient advocacy organization that promotes healthcare value, transparency, and quality--spend time exploring its website)
• Hospital Compare (Centers for Medicare & Medicaid Services, a consumer-oriented website that provides information on how well hospitals provide recommended care to their patients) Start by choosing three local hospitals to compare. See caveats about this site at Ratings for hospitals, doctors, surgeons, home health agencies, nursing homes (a blog post on this site).
• HospitalFinances.org ("Bringing transparency to nonprofit hospital finances"--Association of Health Care Journalists). The site includes details of Form 990 filings made by nonprofit hospitals and systems to the U.S. Internal Revenue Service. It does not include for-profit or government-owned hospitals.
• Hospital Infections (Association of Health Care Journalists: "Bringing transparency to federal inspections.") Search hospital inspections. Links to many other resources (some only for members of AHCJ).
• Hospital Ratings and Reports (The Leapfrog Group) How transparency is driving leaps forward in hospital care in this country. Hospitals across the country demonstrate their commitment to transparency and quality improvement through the Leapfrog Hospital Survey.
• Leapfrog Hospital Safety Grade How safe is your hospital? Check this database to learn what grade it earned.
• Medicare Compare search pages
---Dialysis Compare
---Home Health Compare
---Hospital Compare
---Inpatient Rehabilitation Facility Compare
---Long-Term Care Hospital Compare
---Medicare Plan Finder
---Nursing Home Compare
---Physician Compare

• Medicare Provider Utilization and Payment Data (CMS.gov--Centers for Medicare and Medicaid Services). CMS has released a series of publicly available data files that summarize the utilization and payments for procedures, services, and prescription drugs provided to Medicare beneficiaries by specific inpatient and outpatient hospitals, physicians, and other suppliers.
• The Never Events Collaborative (The Patient Safety Network of the Agency for Healthcare Research and Quality).
• Never Events The term "Never Event" was first introduced in 2001 by Ken Kizer, MD, former CEO of the National Quality Forum (NQF), in reference to particularly shocking medical errors—such as wrong-site surgery—that should never occur. Over time, the term's use has expanded to signify adverse events that are unambiguous (clearly identifiable and measurable), serious (resulting in death or significant disability), and usually preventable. Since the initial never event list was developed in 2002, it has been revised multiple times, and now consists of 29 "serious reportable events" grouped into 7 categories:
Surgical or procedural events
Product or device events
Patient protection events
Care management events
Environmental events
Radiologic events
Criminal events.
• Nonprofit Explorer. Pro Publica's database provides summary data for nonprofit tax returns and PDFs of full Form 990 documents, including those for most nonprofit hospitals.
• Open Payments (Openpaymentsdata.cms.gov) The Open Payments Search Tool is used to search payments made by drug and medical device companies to physicians and teaching hospitals.
• Quality Check Search and compare hospitals that have received a gold seal of approval by The Joint Commission, which oversees the accreditation and certification of nearly 21,000 healthcare organizations and programs in the U.S.
• Ratings for hospitals, doctors, surgeons, home health agencies, nursing homes (links to various rating systems and ratings--invaluable information, available publicly--be a smart patient and check things out!)
• Surgeon Scorecard (Sisi Wei, Olga Pierce and Marshall Allen, ProPublica, 7-15-15) Guided by experts, ProPublica calculated death and complication rates for surgeons performing one of eight elective procedures in Medicare, carefully adjusting for differences in patient health, age and hospital quality. Use this database to know more about a surgeon before your operation.

INFORMATIVE ARTICLES and BOOKS
• When Hospitals Merge to Save Money, Patients Often Pay More (Reed Abelson, NY Times, 11-4-18) The nation’s hospitals have been merging at a rapid pace for a decade....The hospitals have argued that consolidation benefits consumers with cheaper prices from coordinated services and other savings. But an analysis conducted for The New York Times shows the opposite to be true in many cases. The mergers have essentially banished competition and raised prices for hospital admissions in most cases...The analysis showed that the price of an average hospital stay soared, with prices in most areas going up between 11 percent and 54 percent in the years afterward, according to researchers from the Nicholas C. Petris Center at the University of California, Berkeley. The new research confirms growing skepticism among consumer health groups and lawmakers about the enormous clout of the hospital groups. While most political attention has focused on increased drug prices and the Affordable Care Act, state and federal officials are beginning to look more closely at how hospital mergers are affecting spiraling health care costs."
• Emergency rooms are monopolies. Patients pay the price. (Sarah Kliff, Vox, 12-4-17) New data shows how emergency rooms take advantage of their market share, at the expense of their patients.
• Healthcare Associated Infections (Neverevents.org) Learn about MRSA, C.Diff infections, CLABSI infections, CAUTI infections, VAP infections, prevention of infection events.
• Hospitals find asthma hot spots more profitable to neglect than fix (Jay Hancock, Rachel Bluth of Kaiser Health News and Daniel Trielli of Capital News Service, Washington Post, 12-4-17) Baltimore paramedic crews make more asthma-related visits per capita in 21223 than anywhere else in the city, according to fire department records. It is the second-most-common Zip code among patients hospitalized for asthma, which, when addressed properly, should never require emergency visits or hospitalization. This neighborhood in southwest Baltimore is in the shadow of prestigious medical centers — Johns Hopkins, whose researchers are international experts on asthma prevention, and the University of Maryland Medical Center (UMMC). Both receive massive tax breaks in return for providing “community benefit,” a poorly defined federal requirement that they serve their neighborhoods. But like hospitals across the country, the institutions have done little to address the root causes of asthma. The perverse incentives of the health-care payment system have long made it far more lucrative to treat severe, dangerous asthma attacks than to prevent them.
• How Much Hospitals Charge For the Same Procedures (New York Times)
• How to Choose a Hospital (Joel Keehn, Consumer Reports, 3-30-17)
• 60 things to know about the hospital industry | 2016 (Becker's Hospital Review, 1-14-16)
• Lawsuit accuses HCA hospital of covering up medical error that led to patient's death (Megan Knowles, Becker's Hospital Review, 6-21-18) A good website to explore if you're digging deep for information.
• Maximizing Infection Protection in the Next Decade: Defining the Unacceptable (Thomas R. Frieden, Infection Control and Hospital Epidemiology, Oct. 2011) Thomas R. Frieden, Director of the CDC, has stated “Evidence indicates that, with focused efforts, these once formidable infections can be greatly reduced in number, leading to a new normal for healthcare-associated infections as rare, unacceptable events."
• The Problem With Satisfied Patients (Alexandra Robbins, The Atlantic, 4-17-15) A misguided attempt to improve healthcare has led some hospitals to focus on making people happy, rather than making them well.
• Overuse of healthcare. See The Treatment Trap: How the Overuse of Medical Care is Wrecking Your Health and What You Can Do to Prevent It by Rosemary Gibson and Janardan Prasad Singh
• What journalists should know about hospital ratings (Liz Seegert, Covering Health, Association of Health Care Journalists, 6-24-16) "Journalists should take hospital ratings with a healthy dose of skepticism, according to experts at a recent AHCJ New York chapter event. Simply looking at an institution’s overall rating is just the start. Reporting that without understanding what’s being rated and how ';success' is measured does a disservice to your audience."What Makes A Good Surgeon? What Makes A Good Hospital? (Norman Bauman, Veins1.com, 9-10-07). Basically you get the best results in a hospital that does a lot of a particular procedure, and at that hospital, you get the best results with a surgeon who specializes in that procedure.
• Why Hospitals Need to Share Heart Surgery Success Rates (Catherine Roberts, Consumer Reports, 4-6-17) Consumers deserve full transparency about the performance of the hospitals they choose.
• Why Markets Can't Cure Health Care (Paul Krugman, NY Times, 7-25-09)
• Why Not the Best? (WNTB) Select and compare hospitals by region, health system, size, ownership, or type. Explore performance variation among different hospital groupings - by size, ownership, or type. Compare regions: Explore aggregate performance and population health in U.S. counties, hospital referral regions, and states. These data are Medicare/​Medicaid discharges only.
• Yale-New Haven Hospital U.S. News ranking remains high but dips slightly (Ed Stannard, New Haven Register, 7-21-15) 'In addition to the complex care procedures, U.S. News rated the nation’s hospitals in five “common care” procedures that most hospitals perform, whether they are trauma centers like Yale-New Haven or less specialized hospitals. While it ranks high in specialties such as diabetes and gynecology, Yale-New Haven is rated average in heart bypass, hip replacement and heart failure and below average in knee replacement and chronic obstructive pulmonary disease. “Yale did not distinguish itself,” Harder said. “It was average or below average in each of those areas.”
---Best Hospitals for Adult Cancer (U.S. News & World Report)
---Best Hospitals for Adult Cardiology & Heart Surgery (U.S. News & World Report)
---Best Children's Hospitals 2015-16 (U.S. News & World Report)
---Best Hospitals for Adult Neurology & Neurosurgery

• Think drug costs are bad? Try hospital prices (Bob Herman, Axios, 7-25-18) Several pharmaceutical companies have recently said they'll delay some of their price increases, under pressure from the Trump administration. But hospitals have made no such concessions, even though they make up a much larger share of total health care spending. See Bitter Pill: Why Medical Bills Are Killing Us (Stephen Brill, Time magazine, 3-4-13), See full story and sidebars, including Tips for Lowering Your Medical Bill.)
• Senators Unveil Legislation to Protect Patients Against Surprise Medical Bills (Rachel Bluth, KHN, 9-19-18) With frustration growing among Americans who are being charged exorbitant prices for medical treatment, a bipartisan group of senators Tuesday unveiled a plan to protect patients from surprise bills and high charges from hospitals or doctors who are not in their insurance networks. The draft legislation, which sponsors said is designed to prevent medical bankruptcies, targets three key consumer concerns:
---Treatment for an emergency by a doctor who is not part of the patient’s insurance network at a hospital that is also outside that network.
---Treatment by an out-of-network doctor or other provider at a hospital that is in the patient’s insurance network.
---Mandated notification to emergency patients, once they are stabilized, that they could run up excess charges if they are in an out-of-network hospital.
• New Medicare Advantage Tool to Lower Drug Prices Puts Crimp in Patients’ Choices (Susan Jaffe, KHN, 9-17-18) Starting next year, Medicare Advantage plans will be able to add restrictions on expensive, injectable drugs administered by doctors to treat cancer, rheumatoid arthritis, macular degeneration and other serious diseases. Under the new rules, these private Medicare insurance plans could require patients to try cheaper drugs first. If those are not effective, then the patients could receive the more expensive medication prescribed by their doctors.
• A Guide On How To Fight Your Outrageous Hospital Bill (And Win) Gemma Hartley On Assignment for HuffPost, 8-4-17 Document everything. (Watch the video, too.) "I also did a bit of sleuthing and found that putting in a higher entry level, known as upcoding, can drastically hike up ER bills. While I didn’t realize it at the time, it’s illegal." "Had I known to use the word “upcoding” in my first conversation with the billing department, I might have saved hours spent on the phone. Fortunately, I kept careful records, which gave me the upper hand, but I shouldn’t have spent two years of stressful fighting when they were so clearly in the wrong."
• A Denver-area hospital sued a patient for nearly $230,000 over her surgery bill. A jury said not so fast. ( Christopher N. Osher, Denver Post, 6-29-18) Back surgery patient French said she was told by hospital officials prior to surgery that after her insurance kicked in, she would owe just $1,336, of which she immediately paid $1,000. The jury decided that under the hospital contract she signed, French should only have to pay “the reasonable value of the goods and services provided to her.” Evidence submitted during the trial showed that 13 spinal-implant materials installed in French during her spinal-fusion surgeries cost the hospital $31,665.05. The hospital had turned around and charged French $197,640 for those implants, a markup of more than 500 percent, the evidence showed.The jury affirmed in its judgment that it did not believe the hospital’s bill had been reasonable. "What bothered me is they say they are a nonprofit hospital, but how much profit did they need to make?” French said in a recent interview.
• Bad Bedside Manna: Bank Loans Signed in the Hospital Leave Patients Vulnerable (Shefali Luthra, KHN, 2-21-18) Hospitals are increasingly offering “patient-financing” strategies, cooperating with financial institutions to offer on-the-spot loans to make sure patients pay their bills. Private doctors’ offices and surgery centers have long offered such no- or low-interest financing for procedures not covered by insurance, but promoting bank loans at hospitals and, particularly, emergency rooms raises concerns, experts say. "Low-income patients without insurance likely will not need loans to finance large bills, because they should quality for aid from the hospital, or be treated as charity care, Napier said." Read the full article before you get to an ER, so you won't be misled to accept one of these loans. The "cost estimates provided — likely based on a hospital’s list price — may be far higher than the negotiated rate ultimately paid by most insurers." Mark Rukavina, an expert in medical debt and billing, says, “If you pay zero percent interest on a seriously inflated charge, it’s not a good deal.”
• Why a simple, lifesaving rabies shot can cost $10,000 in America (Sarah Kliff, Vox, 2-7-18) Untreated rabies is always fatal — but key drugs leave families with thousands in medical debt. In England, the drug to treat rabies exposure costs $1,600. Here, hospitals charge $10,000. ERs typically are the only locations where patients can find the lifesaving treatment. And they charge significant “facility fees” to anyone who walks through their doors to seek treatment — including patients seeking a rabies vaccine.
• How ER Bills Can Balloon By As Much As $50K For ‘Trauma Response’ (Jenny Gold and Sarah Kliff, Vox and KHN, 7-2-18) On the first morning of Jang Yeo Im’s vacation to San Francisco in 2016, her 8-month-old son, Park Jeong Whan, fell off the bed in the family’s hotel room and hit his head. There was no blood, but the baby was inconsolable. Jang and her husband worried he might have an injury they couldn’t see, so they called 911, and an ambulance took the family — tourists from South Korea — to Zuckerberg San Francisco General Hospital (SFGH). Two years later, the bill finally arrived at their home: They owed the hospital $18,836 for a visit lasting three hours and 22 minutes, the bulk of which was for a mysterious fee for $15,666 labeled “trauma activation,” also known as “a trauma response fee” (charged for activating the trauma response team). If the patient arrives and does not require at least 30 minutes of critical care, the trauma center is supposed to downgrade the fee to a regular emergency room visit and bill at a lower rate, but many do not do so. “Some hospitals are turning this into a cash cow on the backs of patients.” Unfortunately, outside of Medicare and state hospitals, regulators have little sway over how much is charged. And at public hospitals, such fees may be a way to balance government budgets.
• An ER visit, a $12,000 bill — and a health insurer that wouldn’t pay (Sarah Kliff, Vox, 1-29-18) Anthem's emergency room coverage denials are inappropriate. Their new insurance policy expects patients to diagnose themselves. These denials are made after patients visit the ER, sometimes based on the diagnosis after seeing a doctor, not on the symptoms that sent them. The Anthem policy has so far rolled out in four states: Georgia, Indiana, Missouri, and Kentucky.
• 5 Most Common Medical Billing and Coding Errors (Bethany Nock, Ease the Way blog, Gebauer.com, 5-11-17)
• The problem is the prices (Sarah Kliff, Vox, 10-16-17) Health care prices in America are high — and they are secret. Vox looked into Anthem’s practice of denying emergency room visits as part of a year-long project on emergency room billing. It relies on a database of readers’ own emergency room bills. Hospitals keep ER fees secret. Share your bill to help change that. (share your bill with Sarah Kliff at Vox)
• National Health Care Fraud Foundation (NHCFF) A private-public partnership against health care fraud.
• Sessions announces "largest health care fraud takedown" in U.S. history (John Bat, CBS News, 7-13-17)
• Selected Cases (U.S. Dept. of Justice) Cases involving ambulance services, billing firms, clinics, Defective Pricing and Buy America Act Violations: Drugs and Supplies, durable medical equipment suppliers, group homes, home health services, home infusion therapy, hospitals, insurance companies, laboratory services, lymphedema pumps, HHS IG and the FBI: Nursing homes, pharmaceutical and pharmaceutical firms, physicians and other practitioners, psychiatrists, psychiatric hospitals, and mental health services, staged automobile accidents/​workers compensation fraud, miscellaneous.
• 8 Things You Should Know About Challenging A Medical Bill (Kate Ashford, Forbes, 8-15-14)
• 4 Medical Bill Myths That Can Cost You Dearly (Gerri Detweiler, Credit.com, 3-7-12)
Myth 1: As long as I am making payments on a medical bill, it can’t be sent to collections.
Myth 2: I have to be notified before a medical bill is turned over for collections.
Myth 3: Medical collection accounts are treated differently than other types of collection accounts when credit scores are calculated.
Myth 4: To clean up my credit, I need to pay off medical collection accounts.

A lot of the stories below are about price-gouging in the ER departments of hospitals. My fairly recent experience with Urgent Care was more positive. I wasn't feeling well for several days, and my doctor was out of town when I called to report a fever of 105.9. His assistant said to take a tepid bath--with no follow-up. On day 5 a neighbor took me to an Urgent Care facility on Rockville Pike, and the doctor there called an ambulance, which rushed me to a hospital. That facility provided faster triage than I would have gotten at an ER, and I suspect arriving in an ambulance got me into a room faster than walking in the door would have. (I was hospitalized for four weeks.)
• A Quicker Trip to the Doctor, for Minor Ailments (Ann Carrns, Your Money, NY Times, 12-19-13) “Typically, co-payments are more than an office visit but less than an emergency room visit.” Questions to ask.
• Spurred by Convenience, Millennials Often Spurn the ‘Family Doctor’ Model (Sandra G. Boodman, KHN/​Washington Post, 10-9-18) Calvin Brown doesn’t have a primary care doctor — and the peripatetic 23-year-old doesn’t want one. In his view, urgent care, which costs him about $40 per visit, is more convenient — “like speed dating. Services are rendered in a quick manner.” For millennials, the 83 million Americans born between 1981 and 1996 who constitute the nation’s biggest generation, their preferences — for convenience, fast service, connectivity and price transparency — are upending the time-honored model of office-based primary care. But some experts warn that moving away from a one-on-one relationship may be driving up costs and worsening the problem of fragmented or unnecessary care, including the misuse of antibiotics. Although walk-in clinics may be fine as an option for some illnesses, few are equipped to provide holistic care, offer knowledgeable referrals to specialists or help patients decide whether they really need, say, knee surgery, he noted. Primary care doctors “treat the whole patient. We’re tracking things like: Did you get your mammogram? Flu shot? Pap smear? Eye exam?”Can't Get In To See Your Doctor? Many Patients Turn To Urgent Care (Patti Neighmond, Shots, Morning Edition, NPR, 3-17-16) For many people, the centers have become a bridge between the primary care doctor's office and the hospital emergency room. Urgent care is not meant for life-threatening emergencies, such as a heart attack, stroke or major trauma, doctors say. But it is designed to treat problems considered serious enough to be seen that day — conditions like a cut finger, a sprained ankle, severe sore throat, or the sort of infection 25-year-old Dominique Page recently experienced.
• How Urgent Is ‘Urgent’ Healthcare? (Ashley Rodriguez, Medium, 11-9-15) As walk-in urgent care centers spread, so do questions about their expertise. One thing for sure: They’re not emergency rooms. "More and more medical practices across the country are rebranding themselves as urgent care centers....They sound like places promising the kind of medical attention offered at emergency rooms. As a marketing tool, the phrase 'urgent care' is luring patients with an implicit promise of fast treatment. The reality is that these facilities face much less oversight, and many are not required to have even the basic equipment common in emergency rooms....Unlike emergency rooms, urgent care centers can decide whom they want to treat. They can accept those with insurance or patients who can pay up front. They can turn away patients who cannot pay....they typically refer patients with severe traumas and life-threatening conditions to an emergency room....In New York, where Mandi Patterson wanted care for her son, there are no rules specifically regulating medical standards at urgent care centers, though there are plenty covering emergency rooms."
• Healthcare Bluebook
• 25 Things to Know About Urgent Care (Becker's Hospital Review, 8-19-13)
• A 24/​7 Emergency Room Charges An 'After-Hours' Fee. Who Should Pay? (Michelle Andrews, Shots, NPR, 6-5-18) What do you do when a hospital emergency room tacks on an "after-hours" service charge, and your insurer threatens to not pay it? What happens when Medicare and workers' compensation disagree about which should cover your medical bill? Answers to these and other questions.
• 10 Ways to Deal with an Expensive Emergency Room Bill (Gary Foreman, USNews, 8-16-12)
• Hospitals keep ER fees secret. We’re uncovering them. (Vox, 2-27-18) Reporter Sarah Kliff is collecting emergency room bills as part of a year-long project focused on American health care prices.
• Emergency rooms are monopolies. Patients pay the price. (Sarah Cliff, Vox, 12-4-17) New data shows how emergency rooms take advantage of their market share, at the expense of their patients.
• An ER visit, a $12,000 bill — and a health insurer that wouldn’t pay (Sarah Kliff, Vox, 1-29-18) A new insurance policy from Anthem expects patients to diagnose themselves.
• Outrageous ER Charges: Don't Let Hospital Bills Break the Bank (Nick Tate, NewsMax, 6-9-17) Negotiate costs before receiving care. Don’t pay for ER care right away, or automatically.
• Race Is On to Profit From Rise of Urgent Care (Julie Creswell, Business Day, NY Times, 7-9-14)
• Urgent Care Centers: Good for Patients, Bad for Real Healthcare Reform (Ken Terry, MoneyWatch, CBS, 10-13-10)

• Medicare’s Physician Compare tool lets you know whether your doctor accepts Medicare and takes assignment.
• What You Need to Know When You Go to the Hospital: Before, During, After (Caring Collaborative, Transition Network, 2011)
• Hospital Tips for Seniors and Family Caregivers (Senior Providers Network, 6-12-18)
• Taken For A Ride? Ambulances Stick Patients With Surprise Bills (Melissa Bailey, KHN, 11-27-17) Public outrage has erupted over surprise medical bills — generally out-of-network charges that a patient did not expect or could not control — prompting 21 states to pass laws protecting consumers in some situations. But these laws largely ignore ground ambulance rides, which can leave patients stuck with hundreds or even thousands of dollars in bills, with few options for recourse, finds a Kaiser Health News review of 350 consumer complaints in 32 states. Patients usually choose to go to the doctor, but they are vulnerable when they call 911 — or get into an ambulance. Moreover, many ambulances are not summoned by patients. Instead, the crew arrives at the scene having heard about an accident on a scanner, or because police or a bystander called 911. Today, ambulances are increasingly run by private companies and venture capital firms. e police or a bystander called 911. Forty years ago, most ambulances were free for patients, provided by volunteers or town fire departments using taxpayer money. The core of the problem is that ambulance and private insurance companies often can’t agree on a fair price, so the ambulance service doesn’t join the insurance network. The KHN review of complaints revealed two common scenarios leaving patients in debt: First, patients get in an ambulance after a 911 call. Second, an ambulance transfers them between hospitals. Most complaints reviewed by Kaiser Health News did not appear to involve fraudulent charges. Instead, patients got caught in a system in which ambulance services can legally charge thousands of dollars for a single trip — even when the trip starts at an in-network hospital. Patients do have the right to refuse an ambulance ride, as long as they are over 18 and mentally capable.
• Advance directives, POLSTs, living wills, health care (medical) proxies. In brief (but there is a whole section here): The health care proxy part of the advance directive designates the person who has the authority to make medical treatment decisions for you should you be unable to (say, you've been in an accident and are in a coma). The living will (identifies the types of treatment you do and do not want at the end of your life-- stating your wishes about life-sustaining medical treatment if you are terminally ill, permanently unconscious, or in the end-stage of a fatal illness. The living will part of the advance directive expresses your wishes but it is NOT a medical order. Before you undergo a procedure or surgery it may be even more important to be sure your medical team has a copy of your MOLST, or POLST. The POLST form (aka MOLST, POST, MOST, ETC.) is a medical order--that's the one they're supposed to obey in a medical emergency or a life-threatening situation. Go here for a fuller explanation and links to places where you can get forms for these documents.
• Canadian hospital takes action to prevent delirium (CBC Player, 3-19-18) The Hamilton Health Sciences Centre is taking action to try and prevent delirium before the condition takes hold of the patient. It's being done using a program developed in the U.S. called the Hospital Elder Life Program (HELP). Each year in Canada, 200,000 people who go to hospital may experience delirium, a serious disturbance in mental ability that can leave them confused and frightened
• Hospital Elder Life Program (HELP) for Prevention of Delirium A comprehensive patient-care program that ensures optimal care for older adults in the hospital. HELP prevents delirium (a sudden state of confusion or change in mental state) and loss of functioning.
• Slammed with a Huge ER Bill from an Out-of-Network Doctor or Hospital? Now What? (Sandra Levy, HealthLine, 10-22-14) An increasing number of insured patients are stunned when they receive humongous bills from hospital emergency rooms and “contracted” physicians that are out of their insurance network. You assume, when you go to an in-network hospital, that everyone treating you is in-network ... There is a tiny paragraph [on admission forms] that says, ‘We may use outside doctors that are not part of your network and you are responsible..’ 'Pat Palmer, founder and CEO of Medical Recovery Services, told Healthline that in the past year and a half, she’s seen an increase in hospital ERs using the services of “contracted physicians” or “traveling docs,” as well as outside labs and radiology services. These doctors and services are contracted by the hospital, but they are out of a patient’s insurance network.' Palmer advised patients to inform the ER personnel, and write on the admission form, that you want to be notified of any provider that is not part of your insurance program, or not in-network. When negotiating with the provider, inform them that you never engaged their services directly; someone else engaged their services on your behalf, said Palmer. “Unless they have a signed document from you that you are agreeing to pay them anything they asked for, you want the bill adjusted to what the insurance is allowing,” said Palmer. Read this very practical piece in full!
My friend Ina suggests writing this on any form you sign: "Notwithstanding any other provisions contained herein it is hereby stipulated the patient or other person signing this document is not responsible for any costs, fees or other charges not covered by patient’s insurance policies. Patient will only pay co-payment amounts when approved by patient’s insurance policy companies."
• How To Fight For Yourself At The Hospital — And Avoid Readmission (Judith Graham, Kaiser Health News, 9-1-16) This new column explains what older adults and their families can do to avoid hospital readmission. Kaiser Health News columnist Judith Graham writes: "Everything initially went well with Barbara Charnes’ surgery to fix a troublesome ankle. But after leaving the hospital, the 83-year-old soon found herself in a bad way. Dazed by a bad response to anesthesia, the Denver resident stopped eating and drinking. Within days, she was dangerously weak, almost entirely immobile and alarmingly apathetic. “I didn’t see a way forward; I thought I was going to die, and I was OK with that,” Charnes remembered, thinking back to that awful time in the spring of 2015. Her distraught husband didn’t know what to do until a long-time friend — a neurologist — insisted that Charnes return to the hospital."
• We are in danger of hospitals no longer being safe havens (Andrea Lauffer, Kevin MD, 11-7-18) Unfortunately, there are more security measures found in concert halls, stadiums, and hotels than provided in many hospitals. If we truly want to do no harm, we must work to stop an opportunity for harm to occur.
• When You Need a Home Health Aide (Orly Avitzur, Consumer Reports)
• Diagnosis: Unprepared (KHN) Hospitals can be hazardous places for elderly patients, who are at increased risk of falling, drug-induced injury and confusion. But as the nation’s senior population grows, many facilities are ill-equipped to address their unique needs. Kaiser Health News visited hospitals around the country, reviewed data and interviewed dozens of patients, family members and health providers to document the extent of the problem and highlight possible solutions.
Read the stories in this series:
• Elderly Hospital Patients Arrive Sick, Often Leave Disabled (Anna Gorman, KHN, 8-9-16)
• Geriatric ERs Reduce Stress, Medical Risks For Elderly Patients (Anna Gorman, KHN, 8-23-16) Geriatric emergency rooms, which are slowly spreading across the country, provide seniors with more expertise from physicians, nurses and others trained specifically to diagnose and care for the elderly, researchers said.
• Elderly Patients In The Hospital Need To Keep Moving (Anna Gorman, KHN, 8-16-16) “People walk in the door of a hospital and think it’s OK to stay in a bed. It’s not,” said Middlebrooks. The Affordable Care Act explains some of the reluctance by staff at many hospitals to get patients moving, experts say. Under the law, hospitals are penalized for preventable problems, including falls. Researchers believe that hospital staffers, to ensure their patients don’t fall, often leave them in their beds. The impact of remaining so sedentary in the hospital can be devastating for older patients: It is puts them at greater risk for blood clots, pressure ulcers and confusion. Immobility hurts older patients more than younger ones, in part because the elderly are generally weaker, have less bone density and are at higher risk of falling. Ironically, keeping a patient in bed, which is often intended to prevent falls in the hospital, can increase their risk of falling after they are discharged, experts said.
• ‘America’s Other Drug Problem’: Copious Prescriptions For Hospitalized Elderly (Anna Gorman, Kaiser Health News, 8-30-16)

• A Jolt To The Jugular! You’re Insured But Still Owe $109K For Your Heart Attack (Chad Terhune, KHN, 8-27-18) The heart attack was a shock for Calver, an avid swimmer who had competed in an Ironman triathlon just five months before. The hospital charged $164,941 for his surgery and four days in the hospital. Aetna, which administers health benefits for the Austin Independent School District, paid the hospital $55,840, believing he would not bear much, if any, out-of-pocket payment for his life-threatening emergency and the surgery that saved him. And then the bills came.
• Texas fines Humana for out-of-network anesthesiology bills (Harris Meyer, Modern Healthcare, 10-11-18) In an unusual enforcement action against an insurer for out-of-network billing, Humana will pay Texas a $700,000 fine for failing to maintain an adequate number of in-network anesthesiologists at its contracted hospitals in four counties. It's the latest development in a running national battle over surprise out-of-network bills, which a bipartisan group of U.S. senators recently targeted with draft legislation. The problem is particularly pronounced in Texas, which lacks a comprehensive system for shielding patients from contract disputes between insurers and providers, unlike California and other large states.
• Cutting Higher Payments to Long-Term Care Hospitals Could Save $4.6 Billion (Tara Bannow, Modern Healthcare, 8-27-18) A trio of economists has a suggestion it says will save taxpayers about $4.6 billion per year with no harm to patients: get rid of higher payments to long-term care hospitals. A National Bureau of Economic Research study released Monday found that despite being reimbursed at much higher rates than skilled nursing facilities and home healthcare providers, long-term care hospitals don't produce better outcomes in three important areas: They don't reduce mortality or length of stay and they leave patients with higher out-of-pocket costs.
• Mass. Health Care Groups Come Out Against Plan To Help Small Hospitals (WBUR Newsroom, CommonHealth, 7-20-18) Some Massachusetts health care industry groups are coming out strongly against bills approved by the House and Senate designed to support small community hospitals. "Surprise bills occur when a patient goes to a hospital in his insurance network but receives treatment from a doctor that does not participate in the network, resulting in a direct bill to the patient. They can also occur in cases like Calver’s, where insurers will pay for needed emergency care at the closest hospital — even if it is out-of-network — but the hospital and the insurer may not agree on a reasonable price. The hospital then demands that patients pay the difference, in a practice called balance billing."
• EMMA "Providing Market Transparency Since 2008." Get to know this source for hospital financial reports. The official source for municipal securities data and documents--and the official source for comprehensive annual financial reports and operating information about any hospital or health care facility financed by public debt. See AHCJ's webcast about it 8-2-18)
• Hospitals know how to protect mothers. They just aren't doing it. (Alison Young, USA Today, 7-26-18) "Every year, thousands of women suffer life-altering injuries or die during childbirth because hospitals and medical workers skip safety practices known to head off disaster, a USA TODAY investigation has found. Yet hospitals, doctors and nurses across the country continue to ignore them.... As a result, women are left to bleed until their organs shut down. Their high blood pressure goes untreated until they suffer strokes. They die of preventable blood clots and untreated infections. Survivors can be left paralyzed or unable to have more children....Instead, the U.S. continues to watch other countries improve as it falls behind. Today, this is the most dangerous place in the developed world to give birth."
• Beth Israel-Lahey Merger Would Increase Health Costs By Tens Of Millions A Year, Panel Finds (Martha Bebinger, WBUR, CommonHealth, 7-18-18) A state panel assessing what would be the largest hospital transaction in Massachusetts in more than 20 years finds that the merger could increase health costs by tens of millions of dollars a year. Health economists say hospital reimbursement rates nearly always increase after a merger. The HPC, using hospital records, projects that BILH would treat the smallest share of Medicaid patients and the smallest proportion of nonwhite patients of any large hospital network in eastern Massachusetts. "You don't want to make the situation worse, particularly for vulnerable populations and vulnerable institutions," Altman said. "Savings to the providers does not necessarily result in lower costs and prices to the patient," said GBIO's Bonnie Gilbert.
• Hospital Giants Vie for Patients in Effort to Fend Off New Rivals (Reed Abelson, NY Times, 12-18-17) It’s all about the patient. Or at least about keeping patients and the revenue generated for their medical care. As health care is rocked by deals aimed at shattering traditional boundaries between businesses, some of the nation’s biggest hospital groups are doubling down on mergers that seem much more conventional. Skeptics say some of these hospital deals are more of the same: systems seeking to increase their leverage with insurance companies and charge more for care....But the frenzy of mergers and other alliances taking place also reveals a frantic attempt to court and capture patients as people have more choices about where to go for care. Patients are increasingly relying on walk-in clinics, urgent care centers or an app on their cellphone to check out a nasty rash or monitor their diabetes, and they are looking for places that are both less expensive and more convenient than a hospital emergency room or doctor’s office. The battle is over “the control of the patient,” said Rob Fuller, a heath care lawyer at Nelson Hardiman and a former hospital administrator. As hospital executives see the continued decline of care being delivered within a hospital’s four walls, he said they want to make sure they still have a say over where patients go after a hospital stay or to get treatment for a chronic condition....And the move by the insurers into their traditional territory is making some institutions very nervous. UnitedHealth Group, the giant insurer, is viewed as the greatest threat, underscored by its recent purchase of DaVita Medical Group....The proposed merger of CVS Health, which operates drugstores and a large pharmacy benefit manager, with Aetna, an insurer, also promises to reinvent care by transforming CVS’ roughly 10,000 drugstores into “health care hubs,” where patients can easily seek advice or treatment for anything from a sore throat to heart disease."
• Outsiders Swoop In Vowing to Rescue Rural Hospitals Short on Hope — And Money (Barbara Feder Ostrov, KHN/​The Atlantic, 6-6-18) "The community of Surprise Valley, Calif., is torn over whether to sell its tiny, long-cherished hospital to a Denver entrepreneur who sees a big future in lab tests for faraway patients." A rural northern California community is torn over whether to sell its tiny, long-cherished hospital to a Denver entrepreneur who sees a big future in lab tests for faraway patients. The woes of Surprise Valley Community Hospital reflect an increasingly brutal environment for America’s rural hospitals, which are disappearing by the dozens amid declining populations, economic troubles, corporate consolidation and, sometimes, self-inflicted wounds. Abundant illustrations.
• What Physicians Must Consider Before Selling to Hospitals (Aubrey Westgate, Physicians Practice, 2-6-14) "Across the country, hospital representatives are knocking on the doors of private practices. They come bearing attractive offers — higher compensation, simplification of administrative burdens, security in uncertain times. All physicians have to do is sell their practices and become hospital employees. But as physicians who have already made the transition from owner to employee know, many of the perks associated with employment come with big drawbacks." Insights from the doctors' viewpoint.
• A hospital without patients (Arthur Allen, Politico, 11-8-17) The cutting edge of health care is tucked off a St. Louis highway exit. And it's eerily quiet. "Mercy Virtual is arguably the world’s most advanced example of something gaining momentum in the health care world: A virtual hospital, where specialists remotely care for patients at a distance. It's the product of converging trends in health care, including hospital consolidation, advances in remote-monitoring technology and changes in the way medicine is paid for....In the near future, the hospital’s administrators believe, instead of earning fees for each treatment administered, insurers and the government will pay Mercy Virtual to keep patients well. A visit to the hushed carrels and blinking monitors is a glimpse into a future in which hospital systems are paid more when their patients are healthy, not sick."
• How hospitals got richer off Obamacare (Dan Diamond, Politico, 7-17-17) After fending off challenges to their tax-exempt status, the biggest hospitals boosted revenue while cutting charity care. A decade after the nation’s top hospitals used all their advertising and lobbying clout to keep their tax-exempt status, pointing to their vast givebacks to their communities, they have seen their revenue soar while cutting back on the very givebacks they were touting, according to a POLITICO analysis.
• Angered by high prices and shortages, hospitals will form their own generic drug maker (Ed Silverman, Pharmalot, 1-18-18) Angered by rising prices and persistent shortages of generic drugs, four of the nation’s largest hospital systems are forming a new, not-for-profit manufacturer.
• Pharma Has Another Reason To Look Out -- Healthcare Systems Now Plan To Make Their Own Drugs ( John Nosta, Forbes, 1-18-18) Intermountain Healthcare is leading a collaboration with Ascension, SSM Health, and Trinity Health, in consultation with the U.S. Department of Veterans Affairs, to form the company. The five organizations represent more than 450 hospitals around the U.S. "The new company intends to be an FDA approved manufacturer and will either directly manufacture generic drugs or sub-contract manufacturing to reputable contract manufacturing organizations, providing patients an affordable alternative to products from generic drug companies whose capricious and unfair pricing practices are damaging the generic drug market and hurting consumers."
• The ‘Frequent Flier’ Program That Grounded a Hospital’s Soaring Costs (Arthur Allen, Politico, 12-18-17) In Dallas, Parkland Hospital created an information-sharing network that gets health care to the most vulnerable citizens—before they show up in the emergency room. "Parkland Center for Clinical Innovation (or PCCI) was a joint effort with community partners such as homeless shelters and food pantries to build a network of what was hoped would eventually be hundreds of community-based social services around Dallas County, with Parkland Memorial at the center of it. A sophisticated software platform would enable the hospital to easily refer homeless people discharged from its emergency room to shelters and pantries, and to let social workers at those places see what their clients were doing: whether they were filling their prescriptions, or getting healthy food, or had a place to sleep, or money for the bus. It would be so much cheaper to meet those needs outside the medical system than to pay for the consequences inside it. Two years into the program, evidence is mounting that PCCI is working."
• 769 hospitals see Medicare payments cut over high HAC rates: 7 things to know (Morgan Haefner, Becker's Hospital Review, 12-22-16) "The federal government will cut 769 hospitals' Medicare payments in fiscal year 2017 for having the highest rates of hospital-acquired conditions."
• Penalty Calculations (Globe1234.info)
• Hospital-Acquired Condition Reduction Program (hospitals getting a 2018 penalty for HAC: HOSPITAL ACQUIRED CONDITIONS are identified in a column near the right edge)
• Hospital Inpatient Quality Reporting Program Hospitals eligible for the Hospital Inpatient Quality Reporting (IQR) Program are included annually in one of three lists.

• Dignity Health and Catholic Health Initiatives to Combine to Form New Catholic Health System Focused on Creating Healthier Communities (DignityHealth.org) Key strategic and reinvestment priorities for the new system will include:
---The expansion of community-based care, offering access to services in a variety of outpatient and virtual care settings closer to home;
---Clinical programs focused on special populations and those suffering from chronic illnesses to keep people and communities healthier for longer; and
---Further advancement of digital technologies and innovations like stroke robots and Google Glass, which create a more personalized and efficient care experience.

• Choosing Wisely (Consumer Reports and the American Board of Internal Medicine (ABIM) Foundation) Helps consumers/​patients choose care that is truly necessary, is supported by evidence, and doesn’t duplicate tests or procedures already received.
• The Heart of the Matter (transcript for a video that is no longer available). Karen Carey is a Perth woman who grew up with a simple heart problem. At 13 she was diagnosed with a mitral valve prolapse. She learned the hard way that health care decisions doctors make for profit affect patients' lives. Later in life she had two strokes caused by clots breaking off from a mechanical heart valve and lodging in her brain. She sued and lost and became a consumer health care advocate, advising people to ask doctors these three questions when faced with a medical decision: What are my treatment options? What are the expected outcomes, including the complications? And how likely is it that each of those outcomes will occur, including success and complications? Karen's doctors had not told her about the cumulative nature of the risk, the fact that with heart valve surgery the risk of clotting and stroke is cumulative--adds on each year.
• Consumer Health Choices (Consumer Reports, free resources for more sensible healthcare decisions)
• Preventing Overdiagnosis (winding back the harms of too much medicine)
• Right Care Weekly (Lown Institute)
• Modifying use of some prescription drugs may reduce fracture risk in older adults (Liz Seegert, Covering Health, AHCJ, 9-13-16) Some fragility fractures – those that occur at standing height – may be preventable by modifying a patient’s prescription drug regimen. 21 drug classes have been associated with increased fracture risk. These include commonly prescribed medications such as antidepressants and antacids.
• When Evidence Says No, but Doctors Say Yes (David Epstein and Pro Publica, The Atlantic, Feb. 2017) Long after research contradicts common medical practices, patients continue to demand them and physicians continue to deliver. The result is an epidemic of unnecessary and unhelpful treatments. "How can a procedure so contraindicated by research be so common?""Atenolol did not reduce heart attacks or deaths—patients on atenolol just had better blood-pressure numbers when they died.""“If the treatment were Pixy Stix, you’d have a similar effect. One group gets Pixy Stix, and when their cancer progresses, they get a real treatment.” “Relative risk is just another way of lying.”

• Antibodies: Friend & Foe (Thomas Packard, Healthcare in America,12-29-16)
• You Should Appreciate Germs (Bill Gates, GatesNotes, 3-26-17) Gates talks with British journalist Ed Yong about his book I Contain Multitudes: The Microbes Within Us and a Grander View of Life. "Yong makes clear that only a tiny fraction of microbes have the ability to make us sick. There are approximately 100 species of bacteria that cause infectious disease in humans. But there are hundreds of thousands of species that live peacefully, symbiotically within us, primarily in our gut. Microbes help us digest our food, break down toxins, guide our physical development, protect us from disease, and even speed human evolution. We are utterly dependent on them." “We have been tilting at microbes for too long, and created a world that is hostile to the ones we need,” says Yong. What we're doing wrong: overusing anti-bacterial soaps and sanitizers, antibiotics (“A rich, thriving microbiome acts as a barrier to invasive pathogens,” writes Yong. “When our old friends vanish, that barrier disappears [and] more dangerous species can exploit the … ecological vacancies.”) We don't give our children enough micronutrients (not available in pizza!) "The list of disorders that have been linked to disruptions in the microbiome includes Crohn’s disease, ulcerative colitis, irritable bowel syndrome, colon cancer, obesity, type 1 diabetes, type 2 diabetes, and Parkinson’s disease. "Blood tests and results, explained
• Blood Pressure Monitors (those validated as reliable, dabl Educational Trust)
• Types of blood tests (National Heart, Blood, and Lung Institute, NHBLI)
• So You Might Actually Not Be Allergic to Penicillin (Jeanette Beebe, Daily Beast, 1-16-18) "Nearly 90 percent of patients who had 'penicillin allergy' listed on their medical charts were found to actually have no such allergy at all....The only way to know if you’re actually allergic to penicillin is a skin test. Khan argues that getting the right diagnosis lowers health care costs and weakens antibiotic-resistant bugs (and infections) for all of us."
• Risk Assessment Tool for Estimating Your 10-year Risk of Having a Heart Attack (NHBLI)
• Questions and Answers on Cholesterol and Health with NHLBI Nutritionist Janet de Jesus, M.S., R.D. (NHBLI)
• Testosterone (This American Life, Program 220, 8-30-2002) Stories of people getting more testosterone and coming to regret it. And of people losing it and coming to appreciate life without it. The pros and cons of the hormone of desire.
• Doctors Might Stop UTIs from Ever Happening Again (Nicole Wetsman, Precise Welfare, Daily Beast, 6-19-18) There are around 8 million urinary tract infections diagnosed each year in the United States, making up around 25 percent of all infections. Unlike traditional antibiotics, which wipe out good and bad bacteria indiscriminately, precision treatments would target the specific bug responsible for the urinary tract infection, while leaving the rest intact.
• Fighting the Plague: A Story of HIV/​AIDS (Thomas Packard, Healthcare in America, 12-2-16)

• Mapping the Secret Lives of Human Cells (Daniela Hernandez, WSJ, 4-6-17) What does a human cell look like? That is somewhat of a mystery because most current cellular models are static and based on limited data, according to scientists from the Allen Institute for Cell Science in Seattle. Until recently researchers lacked the tools to assess cells and their tiny internal structures, known as organelles, in real time on a large scale, they say.
• In Giant Virus Genes, Hints About Their Mysterious Origin (Rae Ellen Bichell, Shots, NPR, 4-6-17) Viruses are supposed to be tiny and simple — so tiny and simple that it's debatable whether they're even alive. They're minimalist packets of genetic information, relying entirely on the cells the infect in order to survive and reproduce. But in 2003, researchers identified a new kind of virus that that turned scientific understanding of viruses upside down, and tested the boundary of what can be considered life.

• The gut microbiome is opening a new field of medicine (Abigail Eisenstadt, AAAS meeting coverage, National Association of Science Writers, 3-10-18)
• When Hong Kong Commuters Take The Subway, Their Microbes Mix – And Spread (Amina Khan, LA Times, 8-1-18) Humans aren’t the only commuters making use of the metro. A new study that examined the microbiome of the Hong Kong subway system found distinct bacterial “fingerprints” in each line during the morning – distinctions that blurred over the course of the afternoon. The findings, published in the journal Cell Reports, are part of a growing body of work that could have implications for a host of efforts, from managing the spread of disease to designing city infrastructure. (Interesting even if you aren't interested in the topic!)
• Researchers warn that evidence about microbiome's role is preliminary (Bara Vaida, Covering Health blog, AHCJ, 4-27-18) "Journalists who write about health claims connected to the microbiome -- the army of bacteria that live on and in the body -- should exercise skepticism because most research has yet to determine the microbiome's precise role in health and disease. In fact, the scientific evidence is still so scant, probiotics sold on the market, like Culturelle, are probably not as beneficial as advertised, two scientists who spoke at AHCJ's annual conference said."
• Microbes in Flux (YouTube video) On that YouTube channel are a dozen YouTube videos about the microbiome.
• A Frozen Idea To Save Helpful Germs From Disasters (Melody Schreiber, WBUR News, 10-4-18) 'Microbiota are the bacteria colonizing the human body — the gut, skin, mouth, and so on — that often help regulate your health. Researchers call them "beneficial germs."' ...Maria Gloria Dominguez-Bello 'has an idea for how to protect those samples from disasters. She is part of a team that wants to build a freezer vault in the safest place possible and stock it with microbiota collected by scientists around the world — a kind of Noah's Ark for helpful bacteria.Right now, many of our probiotics are made with bacteria from cows and other animals.... In the future, Dominguez-Bello says, probiotics will likely come from humans. People may start saving their own microbiota samples before a surgery, she says. After a course of antibiotics, they could reintroduce their helpful bacteria to keep their immune systems flourishing.'
• How to boost your microbiome (Tim Spector, Science Focus, 1-2-18) Practical, do-able tips.

• Human Microbiome Project Highlights (Human Microbiome Project, NIH) Get a cup of your favorite drink and plan to read lots of useful pieces here.
• Some of My Best Friends Are Germs (Michael Pollan, NY Times Magazine, 5-19-13) "Justin Sonnenburg, a microbiologist at Stanford, suggests that we would do well to begin regarding the human body as “an elaborate vessel optimized for the growth and spread of our microbial inhabitants.” This humbling new way of thinking about the self has large implications for human and microbial health, which turn out to be inextricably linked. Disorders in our internal ecosystem — a loss of diversity, say, or a proliferation of the “wrong” kind of microbes — may predispose us to obesity and a whole range of chronic diseases, as well as some infections....Our resident microbes also appear to play a critical role in training and modulating our immune system, helping it to accurately distinguish between friend and foe and not go nuts on, well, nuts and all sorts of other potential allergens. Some researchers believe that the alarming increase in autoimmune diseases in the West may owe to a disruption in the ancient relationship between our bodies and their “old friends” — the microbial symbionts with whom we coevolved." A long, interesting, informative read.
• The gut microbiome is opening a new field of medicine (Abigail Eisenstadt, AAAS meeting coverage, National Association of Science Writers, 3-10-18).
• The gut microbiome in health and in disease (Andrew B. Shreiner, John Y. Kao, and Vincent B. Young), PubMed, NCBI, N IH, 1-31-15) "The human microbiome is composed of bacteria, archaea, viruses and eukaryotic microbes that reside in and on our bodies. These microbes have tremendous potential to impact our physiology, both in health and in disease. They contribute metabolic functions, protect against pathogens, educate the immune system, and, through these basic functions, affect directly or indirectly most of our physiologic functions." "Ongoing efforts to further characterize the functions of the microbiome and the mechanisms underlying host-microbe interactions will provide a better understanding of the role of the microbiome in health and disease."
• Gut Microbiota for Health (European Society for Neurogastroenterology & Motility, o ESNM) "The word microbiota represents an ensemble of microorganisms that resides in a previously established environment. Human beings have clusters of bacteria in different parts of the body, such as in the surface or deep layers of skin (skin microbiota), the mouth (oral microbiota), the vagina (vaginal microbiota), and so on....Gut microbiota (formerly called gut flora) is the name given today to the microbe population living in our intestine. Our gut microbiota contains tens of trillions of microorganisms, including at least 1000 different species of known bacteria with more than 3 million genes (150 times more than human genes)."
• The Uncounted: Part 1: Off the Radar.(Ryan McNeill, Deborah J. Nelson and Yasmeen Abutaleb, A Reuters Investigation, 9-7-16) 'Superbug' scourge spreads as U.S. fails to track rising human toll. The deadly epidemic America is ignoring. Fifteen years after the U.S. declared drug-resistant infections to be a grave threat, the crisis is only worsening, a Reuters investigation finds, as government agencies remain unwilling or unable to impose reporting requirements on a healthcare industry that often hides the problem.
---Part 2: Costly Crisis One life, two donated organs and $5.7 million in bills – a tale of superbugs’ deadly costs
---Part 3: Running Low As ‘superbugs’ strengthen, an alarming lack of new weapons to fight them
---Part 4: Deadly Silence How hospitals, nursing homes keep lethal ‘superbug’ outbreaks secret
---A Most Unwanted List
• The incidence of MRSA infections in the United States: is a more comprehensive tracking system needed? (Kevin T. Kavanagh, Said Abusalem, and Lindsay E. Calderon, Antimicrob Resist Infect Control. 2017--PubMed.
• How To Improve Your Gut Microbiome in A Day (Christiane Northrup) Include fermented foods in your diet. Fermented foods seed your gut with healthy bacteria. Eat sauerkraut, pickles, kimchi, kefir, yogurt (not processed), and kombucha. These foods are rich in prebiotics.
• C-Sections and Gut Bacteria May Contribute to Overweight Kids (Nicholas Bakalar, NY Times, 2-28-18) Overweight mothers are more likely to have overweight babies, and the gut bacteria the babies inherit may in part be to blame. Researchers report that overweight mothers are more likely to have a cesarean section, and that babies born by cesarean to those mothers have species of gut bacteria different from those in babies born to normal weight women. And that difference in the gut microbiome — specifically an abundance of bacteria of the family Lachnospiraceae in infants of overweight mothers — may contribute to an increased risk for obesity. Source: Roles of Birth Mode and Infant Gut Microbiota in Intergenerational Transmission of Overweight and Obesity From Mother to Offspring (JAMA Pediatr., 2-19-18)
• Gut: The Inside Story of Our Body's Most Underrated Organ by Giulia Enders with Jill Enders and David Shaw
• Why the Gut Microbiome Is Crucial for Your Health (Ruairi Robertson, HealthLine, 6-27-17) "While some bacteria are associated with disease, others are actually extremely important for your immune system, heart, weight and many other aspects of health....Most of the microbes in your intestines are found in a "pocket" of your large intestine called the cecum, and they are referred to as the gut microbiome. There are roughly 40 trillion bacterial cells in your body and only 30 trillion human cells. That means you are more bacteria than human."

• Surprisingly Little Evidence for the Accepted Wisdom About Teeth (Aaron E. Carroll, The New Health Care, NY Times, 8-29-16) There’s good evidence that brushing twice a day with fluoride toothpaste is a good idea, especially with a powered toothbrush. For children, there’s good evidence that the use of fluoride varnish or sealants can be a powerful tool to prevent cavities. The rest? It’s debatable; we don't have good studies. With flossing, which is cheap and easy, it still might be worth doing. And fluoride is important.
• ‘Physicians of the Mouth’? Dentists Absorb the Medical Billing Drill (David Tuller, California Healthline, 9-21-18) On a recent Friday morning, more than 30 dentists and dental staffers gathered in a conference room to learn an arcane new skill: how to bill medical insurers. Pacing back and forth, the Florida dentist leading the two-day course advised the participants to stop thinking of themselves as tooth technicians and reposition themselves as “physicians of the mouth.” "The reason is simple: Medical insurance is generally much more generous in its coverage than dental insurance. Unlike medical coverage, dental insurance is mostly geared to the healthy — something many people don’t realize until they experience serious oral problems and get socked with unexpected costs. Standard dental insurance covers cleanings, fillings and other routine care. But major work like a crown or a bridge is often covered only at 50 percent and implants generally aren’t covered at all. And dental insurance is usually capped at $1,000 or $1,500 per year."
• Tooth Wisdom Find affordable dental care.
• Dental health topics, A to Z (Tooth Wisdom)
• The Tooth Divide: Beauty, Class and the Story of Dentistry (Sarah Jaffe, NY Times, 3-23-17) Review of Teeth: The Story of Beauty, Inequality, and the Struggle for Oral Health in America by Mary Otto. "The dividing line between the classes might be starkest between those who spend thousands of dollars on a gleaming smile and those who suffer and even die from preventable tooth decay....Otto’s book begins and ends with the story of Deamonte Driver, a 12-year-old Maryland boy who died of an infection caused by one decaying tooth, and the system that failed him. In pointing out the flaws in that system, Otto takes us back through the history of dentistry and shows us how the dental profession evolved, separately from the rest of health care, into a mostly private industry that revolves almost entirely around one’s ability to pay. In other words, all of the problems with health care in America exist in the dental system, but exponentially more so....dental care is still associated in our minds with cosmetic practices, with beauty and privilege. It is simultaneously frivolous, a luxury for those who can waste money, and a personal responsibility that one is harshly judged for neglecting. In this context, “Teeth” becomes more than an exploration of a two-tiered system — it is a call for sweeping, radical change.
• NY program highlights challenge of providing dental care to patients with disabilities (Mary Otto, Covering Health, AHCJ, 4-11-18) A bill recently signed into law by Arizona Gov. Doug Ducey opens the way for dental therapists to begin providing services in tribal health centers, safety net clinics and other public health settings across the state. Diverse supporters of the change ranged from health advocacy groups and tribal organizations to the libertarian Goldwater Institute, which issued the report, "The Reform That Can Increase Dental Access and Affordability in Arizona." Minnesota was the first state to authorize the licensing of dental therapists and Compromise Would Use Dental Therapists to Expand Access to Oral Health Care in Mass. (Matt Murphy, WBUR, Boston). The American Dental Association says the major problem with disparities in access to health care is the lack of reasonable Medicaid reimbursement, not dental workforce issues--concluding that the therapist model would drive down the cost and price of dental care and the income of dentists while doing little to increase the use of dental services.
• Kentucky reporter shares insights on covering cuts to Medicaid dental coverage (Mary Otto Q&A with reporter Will Wright, who wrote about Kentucky Gov. Matt Bevin’s July decision to cut dental and vision benefits for about 460,000 state Medicaid beneficiaries: Appointments at this Kentucky dental clinic down by half after Bevin’s Medicaid cuts (Lexington Herald-Leader, 7-10-18)
• UI dental school to turn away new Medicaid patients because of low payments, confusing rules (Tony Leys, Des Moines Register, 6-28-18)
• University’s decision exacerbates dental care access crisis for Iowa’s poor (Mary Otto, AHCJ, 8-1-18)
• Confusion Leaves Low-Income Children In Health Care Limbo (Jocelyn Wiener, California Healthline, 9-10-18) Tania Alvarado’s 13-year-old daughter doesn’t smile much anymore. She doesn’t want anyone to see her front teeth, which are so crowded they’re nearly growing atop one another. The crowding makes it painful to eat; it also embarrasses her. “Am I going to get those braces this year?” the Los Angeles eighth-grader asks her mom, again and again. Alvarado always answers her the same way: “It’s still not happening.” For two years, dentists have told Alvarado that her daughter needs braces. They’ve also told her that because the girl has Medi-Cal — the government insurance program for low-income Californians — braces aren’t covered. Legal aid attorneys say the dentists are wrong. Under federal law, children are eligible for a wide array of services, but confused providers and health plans often look only at the state’s narrow range of approved services for adults, and mistakenly apply those rules to kids. “They’re being denied care that they’re entitled to,” she said. “That’s the bottom line.”
• The Unmet Need for Dental Care (scroll through AHCJ's excellent long page on topics related to oral health)
• Unlikely coalition expands use of dental therapists in Arizona (Mary Otto, Covering Health, AHCJ, 7-12-18)
• How Dental Inequality Hurts Americans (Austin Frakt, The Upshot, NY Times, 2-19-18) Lack of dental care through Medicaid not only harms people’s health, but has negative economic implications as well. Not being able to see a dentist is related to a range of health problems. It’s an accident of history that oral care has been divided from care for the rest of our bodies. But it seems less of an accident that the current system hurts those who need it most.
• Basic Dental Care: An Overview (Web MD)
• New guidelines may encourage use of low-cost, painless dental treatment (Mary Otto, Covering Health, AHCJ, 11-20-17) "A treatment that offers a painless, minimally-invasive alternative to drilling and filling teeth has gotten a boost from a prominent children’s dental organization....The product, which is painted onto decayed lesions, contains fluoride, which helps remineralize the damaged tooth, and silver, which kills the bacteria that drive decay. SDF has been used for decades in Japan, but has only recently attracted the attention of U.S. health care providers. n 2014, SDF was cleared by the U.S. Food and Drug Administration to be marketed as a treatment for dental sensitivity in adults. Now, some U.S. dentists have begun using the material as an off-label restorative material."
• Treating Pain Is Not Enough: Why States’ Emergency-Only Dental Benefits Fall Short (Cheryl Fish-Parcham, Families USA, July 2018) States have great latitude to determine the scope of dental benefits that they will cover for adults through their Medicaid programs. While some states cover comprehensive benefits, others cover emergency dental care only or none at all. These states all cover limited services to address severe pain, generally including extractions. Finding appropriate care providers for emergency-only dental services can be difficult. State Medicaid programs end up paying for expensive hospital emergency department visits when appropriate dental services are not available. And most do not provide restorative care nor cleanings that would address underlying disease. When Medicaid does not cover an oral health care need, there are few other resources for low-income adults to get that need met.
• Dearth of dentistry: Reporter explores how state's economic health affects its oral health (Mary Otto, Covering Health, AHCJ, 11-14-17) In this Q&A, Caleb Slinkard, editor of the Norman Transcript, who has overseen his paper’s 15-member newsroom for the past two years, offers insights into his “Dearth of Dentistry” package. He reflects upon what oral health can tell us about economic health and how budget decisions have influenced the availability of benefits, providers and fluoridated water in the state. He also shares tips that might help fellow journalists take a similar look at oral health access in their own communities.
• Maggie Clark’s Two Million Kids series for the Sarasota Herald-Tribune has 'explored many facets of the state’s troubled Medicaid program: a dearth of preventive and specialty care in many communities, problems faced by providers and a decade-long legal battle to reform the system. In a recent installment, Clark focused upon the shortage of oral health care services for Florida’s poor children....Clark looked at how the state’s chronic shortage of Medicaid dental care has affected young Floridians. She delved into how the system got so bad and described how evolving reform efforts, driven by the settlement of a decade-long lawsuit, might improve it....inaccurate provider lists offered to beneficiaries by their Medicaid dental plans further complicated an already difficult search for care, the newspaper found. “For Medicaid-enrolled kids, dental care is an entitlement in federal law,” Scott Tomar, chairman of the Department of Community Dentistry and Behavioral Science at the University of Florida College of Dentistry, told Clark. “The current system is neither adequately funded or user friendly. It seems like it was designed to create as many barriers to utilization for parents, kids and dentists, as possible.”' Poor kids end up in emergency rooms when their dental problems become bad enough, but ER does not provide adequate dental care there. (Hat tip to AHCJ, Covering Health).
• Journal roundtable explores practices to reduce anesthesia-related deaths in pediatric dentistry (Mary Otto, Covering Health, AHCJ, 12-14-17) "Tooth decay remains the most prevalent chronic health problem of children in the United States. Since the late 1980s, roughly one in four U.S. children have had tooth decay, a rate that has remained relatively stable over the decades, according to a new study based on extensive federal data....“Although it is laudable that more younger children are receiving dental treatment for caries, what we would really like to see is more children remaining caries-free through childhood,” Bruce Dye, the study’s lead author. Parents and caregivers should begin getting routine dental care for babies by their first birthday.
• Toothbrushes Buying Guide (Consumer Reports, online)
• Why neglecting your teeth could be seriously bad for your health ( Linda Geddes, The Guardian, 7-19-15) It’s no secret that a lackadaisical approach to dental care leads to fillings and gum disease, but the latest evidence suggests it could also cause diabetes, heart disease and cancer
• Top 10 Facts Your Dentist Wants You to Know (Tammy Davenport, VeryWell, 10-6-16)
• Problems With Dental Fillings (Medicine Net)
• Dentists keep dying of this lung disease. The CDC can’t figure out why. (Cleve R. Wootson Jr., WashPost, 3-10-18) "It’s estimated that about 200,000 people in the United States have Idiopathic Pulmonary Fibrosis (IPF) at any one time.But the common denominator of a small group of patients at a Virginia clinic over a 15-year period is worrying the Centers for Disease Control and Prevention: Eight were dentists; a ninth was a dental technician."
• When Dental Surgery Lands A Patient in a World of Everlasting Regret (Dianna Wray, Houston Press, 8-9-16) It seems there are few rules governing dental surgery and its outcomes in Texas.
• Tip sheet, series provide template for investigating Medicaid dental care for children (Mary Otto, Covering Health, Association for Health Care Journalists, 9-19-16)
• Medicaid Adult Dental Benefits: An Overview (fact sheet from the Center for Health Care Strategies)
• Dentist Participation in Medicaid or CHIP (by state, by gender, by age) (Health Policy Institute, American Dental Association)
• Dental Benefits and Medicaid
• 2018’s States with the Best & Worst Dental Health (WalletHub, 2-1-18)

Annual physicals and health care screening tests Physicals, yes--just not annually. Definitely get a physical when something is wrong.
• A Check on Physicals (Jane Brody, Well, 1-21-13) A 'Danish team noted that routine exams consist of “combinations of screening tests, few of which have been adequately studied in randomized trials.” Among possible harms from health checks, they listed “overdiagnosis, overtreatment, distress or injury from invasive follow-up tests, distress due to false positive test results, false reassurance due to false negative test results, adverse psychosocial effects due to labeling, and difficulties with getting insurance.”'
• Barbara Ehrenreich: Why I’m Giving Up on Preventative Care (Lit Hub, 4-9-18) How Contemporary American Medicine is Testing Us to Death. "What could be more ridiculous than an inner-city hospital that offers a hyperbaric chamber but cannot bestir itself to get out in the neighborhood and test for lead poisoning?" She grudgingly agrees to a bone density scan. "The result was a diagnosis of “osteopenia,” or thinning of the bones, a condition that might have been alarming if I hadn’t found out that it is shared by nearly all women over the age of 35. Osteopenia is, in other words, not a disease but a normal feature of aging. A little further research, all into readily available sources, revealed that routine bone scanning had been heavily promoted and even subsidized by the drug’s manufacturer. Worse, the favored medication at the time of my diagnosis has turned out to cause some of the very problems it was supposed to prevent—bone degeneration and fractures."
• Which screening tests are worth getting? sidebar to story Annual physical exam is probably unnecessary if you’re generally healthy (Christie Aschwanden, Washington Post, 2-8-13).
• Private health screening tests are oversold and under-explained (UK physician Margaret McCartney, The Guardian, 9-17-14) The message in this article for the UK is equally valid for the USA: "Health screening can cause more harm than it prevents, so companies have a duty to provide full information to customers." Life Line Screening markets its for-profit tests without providing fair information and an evidence base for taking them. She provides examples and links, particularly to PrivateHealthScreening: What to Think About When You’re Thinking About Screening Tests. (Click on and read all the links there.) Links below (via Gary Schwitzer) get more specific. Unless your doctor recommends them, there are reasons to think twice about screening tests for which you receive marketing material--say, for aortic aneurysms.
• Screening For Asymptomatic Carotid Artery Stenosis (PDF, Agency for Healthcare Research and Quality, Evidence Synthesis No. 50)
• Screening Asymptomatic Adults With Resting or Exercise Electrocardiography: A Review of the Evidence for the U.S. Preventive Services Task Force (Annals of Internal Medicine, 9-20-11)
• Effect of Screening on Ovarian Cancer Mortality (JAMA, The Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Randomized Controlled Trial, June 8, 2011)
• The UK NSC policy on Osteoporosis screening in women after the menopause (Systematic screening in postmenopasual women is not recommended.)
• Liver function tests in patients with computed tomography demonstrated hepatic metastases (Springer, 1989) "Although liver function tests (LFTs) (enzyme levels) are inexpensive and simple to perform, they failed to detect a significant number of patients with liver metastases."
• Incidental Findings on Brain MRI in the General Population (New England Journal of Medicine, 11-1-07). "Incidental brain findings on MRI, including subclinical vascular pathologic changes, are common in the general population. The most frequent are brain infarcts, followed by cerebral aneurysms and benign primary tumors. Information on the natural course of these lesions is needed to inform clinical management." See full discussion.
• "Preventive health screenings" that are hardly a Life Line (Dr. Kenny Lin, Common Sense Family Doctor, 2-7-11)
• How Doctors and Patients Do Harm (Tara Parker-Pope, Well, NY Times, 4-20-12). "That was the beginning of Otis Brawley becoming a loudmouth in the prostate cancer screening debate. We’re making promises to patients and making them think we know things we don’t know and making money off of them. There is a subtle little corruption in medicine. We’re selling chemo to people who don’t need it, giving prostate screening when it might save lives, but we make them think it definitely does..."
• Articles about screenings (Covering Health, Association of Health Care Journalists).
• Iowa hospitals drop controversial mobile testing firm ( Tony Leys, Des Moines Register, 9-5-14). University of Iowa Health Alliance plans to stop using HealthFair, "a mobile heart-testing company that has been accused of 'fear-mongering' to induce healthy people to undergo scans of their hearts and arteries." This came about after the advocacy group Public Citizen called for an investigation and a halt to recommending tests for most patients. "Such widespread screenings are not recommended by medical experts because each of the six tests either benefits only appropriately selected high-risk patients or has not been scientifically shown to provide any clinically meaningful benefit to anyone.

Many diseases and conditions are listed on this website (with links) under Coping with chronic, rare, and invisible diseases and disorders . When you reach a blog about a particular condition, look along the right side of the page and you'll usually find a "blog roll," listing other resources on the same subject. Some will provide more reliable information and insights than others, but patient-written blogs (which may certainly contain misinformation) often provide practical insights into how to live with a disease or condition (psychologically and otherwise).

Have you noticed that the price for your vitamins and supplements has been rising? The Food and Drug Administration (FDA) does not regulate the safety and sale of nutritional supplements. Because they're classified as food products, not medicines, they aren't regulated by the strict standards governing the sale of prescription and over-the-counter drugs.
• Risky stimulants turn up — again — in weight loss and workout supplements (Rebecca Robbins, STAT News, 11-8-17) "The ingredients, apparently new, were popping up on the labels of dietary supplements marketed for weight loss and workouts. Sometimes the label said DMHA. Sometimes, Aconitum kusnezoffii. Or other, even harder-to-parse names... Octodrine did indeed show up in one of the products Cohen analyzed. But the others contained three different stimulants, with unknown or potentially risky side effects. They could speed up heart rate and raise blood pressure. And none, including octodrine, has gone through the process required by the FDA to be included as ingredients in dietary supplements...The new findings also highlight just how hard it has been for the FDA to keep potentially unsafe supplement ingredients off the market. For example, regulators warn that the best-known of these stimulants, called DMAA, can cause cardiovascular problems ranging from shortness of breath to a heart attack."
• Fish Oil and Vitamin D Pills No Guard Against Cancer or Serious Heart Trouble (Liz Szabo, KHN, 11-10-18) A widely anticipated study has concluded that neither vitamin D nor fish oil supplements prevent cancer or serious heart-related problems in healthy older people, according to research presented Saturday at the American Heart Association Scientific Sessions. Researchers defined serious heart problems as the combined rate of heart attacks, stroke and heart-related deaths. The study also suggests there’s no reason for people to undergo routine blood tests for vitamin D. (Vitamin D testing has become a huge business for commercial labs — and an enormous expense for taxpayers.) But Manson's team also found no serious side effects from taking either fish oil or vitamin D supplements. When researchers singled out heart attacks — rather than the rate of all serious heart problems combined — they saw that fish oil appeared to reduce heart attacks by 28 percent, Manson said. As for vitamin D, it appeared to reduce cancer deaths — although not cancer diagnoses — by 25 percent. (Slicing the data into smaller segments — with fewer patients in each group — can produce unreliable results. The links between fish oil and heart attacks — and vitamin D and cancer death — could be due to chance, Kramer said.) Experts agree that vitamin D is important for bone health. Consumers who want to reduce their risk of cancer and heart disease can follow other proven strategies. “People should continue to focus on known factors to reduce cancer and heart disease: Eat right, exercise, don’t smoke, control high blood pressure, take a statin if you are high risk,” said Dr. Alex Krist, a professor of family medicine and population health at Virginia Commonwealth University.)
• Knowing What’s Worth Paying For in Vitamins Lesley Alderman, NY Times, Patient Money, NY Times, 12-4-09) Use only what you need: "Popping too many vitamin pills is not only a waste of money but can be bad for your health. Talk to your doctor about what added vitamins or minerals you might require; you can ask for a blood test to learn what you might be lacking." A multivitamin will not provide the level of a vitamin you may be deficient in. If your doctor recommends a specific supplement, like omega-3, ask in what form you should be taking it. Find a reputable source. "Purchase your vitamins from well-known retailers that do a brisk business and restock frequently, whether that’s Costco or Drugstore.com." Price may not indicate quality."ConsumerLab.com says it has found a few patterns that consumers may find helpful. Products sold by vitamin chains tend to be more reliable than drugstore brands, and Wal-Mart and Costco’s vitamin lines are usually worth considering. In a recent test of multivitamins, ConsumerLab.com found that Equate-Mature Multivitamin 50+ sold by Wal-Mart was just as good as the name brand Centrum Silver, but at less than a nickel a day is half the price."
• Are Calcium Supplements Safe? (Richard Klasco, NY Times, 10-12-18) Kidney stones are a known risk, but studies have investigated other potential safety concerns, including an increased risk of death, cancer and heart disease. Many people, especially women, take calcium supplements in the hope of building stronger bones, but whether calcium supplements prevent fractures remains uncertain. "The Women’s Health Initiative, a randomized placebo-controlled trial of calcium and vitamin D in more than 36,000 postmenopausal women, found a 17 percent increase in the incidence of kidney stones. A report prepared for the Preventive Services Task Force supported this conclusion, but noted that the risk disappeared when calcium was taken without vitamin D."
• ConsumerLab.com. Among sources ConsumerLab.com recommends for buying vitamins, supplements, and "natural products" (but check their site!):
---eVitamins
---Lucky Vitamin
---Swanson Vitamins
---iHerb
---VitaCost
Check the price at your local store against prices for the same product on Amazon. They are often notably higher at the vitamin shop I have frequented.
• Supplements Can Make You Sick (Jeneen Interlandi, Consumer Reports, 7-27-16) Dietary supplements are not regulated the same way as medications. This lack of oversight puts consumers' health at risk.
• Vitamin B.S. (Cari Romm, The Atlantic, 2-26-15) How people came to believe the myth that nutritional supplements could make them into better, healthier versions of themselves. From an interview with Catherine Price, the author of Vitamania (for which I've seen two different subtitles: "How Vitamins Revolutionized the Way We Think About Food" and "Our Obsessive Quest for Nutritional Perfection").
• What Heart Patients Need to Know About Herbal Supplements (Lauren Friedman, Consumer Reports, 3-2-17) A new study says they may be an especially risky choice for patients taking heart meds
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• Liver Damage From Supplements Is on the Rise (Lauren Cooper, Consumer Reports, 5-19-17) Green-tea extract and bodybuilding pills pose a particular risk, study finds
• The Truth About Calcium and Vitamin D Supplements (Lauren Cooper, Consumer Reports, 7-27-16) Consumers take them to strengthen bones and prevent fractures. Do they work? "Taking daily calcium pills can increase bone density in people over 50 years old by 1 to 2 percent—not enough to prevent fractures. That’s according to a review of 59 randomized controlled trials, published last year in the British Medical Journal. “That small gain is not worth the risks, including an increased likelihood of heart disease, kidney stones, and gastrointestinal problems,” Lipman says."
"The best way to get that calcium is to eat calcium-rich foods including milk, cheese, and yogurt. Good sources of vitamin D are mushrooms, eggs, fortified milk, soy beverages, and salmon. Our bodies also make vitamin D when our skin is exposed to sunlight, so our experts suggest getting 10 minutes of sunshine per day. Exercise is important, too. “Weight-bearing aerobic activities, such as walking and dancing, may slow bone loss."
• 15 Supplement Ingredients to Always Avoid (Consumer Reports, 3-21-17) These supplement ingredients can cause organ damage, cardiac arrest, and cancer: Aconite, caffeine powder, chaparral, coltsfoot, comfrey, germander, greater celandine, green tea extract powder, kava, lobelia, methylsynephrine, pennyroyal oil, red yeast rice, usnic acid, yohimbe. A useful chart with "claimed benefits" vs. "risks."
• 4 Supplements to Question After Age 50 (Lauren Cooper, Consumer Reports, 12-16-16) Who might need folic acid, calcium, iron, and vitamin E supplements, do they do what is claimed, and what problems might there be with them (for whom).
• Fish Oil Supplements May Not Help Prevent Heart Disease (Sally Wadyka, Consumer Reports, 3-14-17) Those who already have certain forms of heart disease may benefit, though, a new report finds. "One thing most heart disease experts do agree on: The best way to get the protective benefits of omega-3s is to eat fish rather than take fish oil supplements.Salmon, sardines, mackerel, and other fatty fish, have the highest amount of omega-3s, and are low in mercury. Fish may be protective, says Lipman, not just because of its omega-3 content, but because it is a lean source of protein, low in saturated fat, and rich in other nutrients.:
• ‘Natural’ Sleep Supplements Carry Serious Safety Concerns (Ginger Skinner, Consumer Reports, 12-29-16) There's little research to suggest melatonin and valerian work, plus the popular supplements come with clear risks

• Hearing Amazon's footsteps, Walgreens unveils new digital platform to connect patients to doctors (Lisa Schencker, Chicago Tribune, 7-27-18) "Walgreens has unveiled a new digital platform to connect customers to medical services, just weeks after its stock dove on news that Amazon is expanding into the pharmacy business. Deerfield-based Walgreens’ new Find Care Now platform, available online and on the pharmacy chain’s app, allows patients to schedule appointments at its in-store Advocate clinics, talk with doctors and therapists through telehealth company MDLIVE, and schedule online dermatology appointments through online dermatology service DermatologistOnCall. Patients can also get second opinions through the NewYork-Presbyterian health care system and make eye and hearing appointments at Walgreens stores. In other parts of the country, Walgreens has partnered with a number of other regional health care providers. "
• More Than Half of Kaiser Permanente's Patient Visits Are Done Virtually (Kia Kokalitcheva, Fortune, 10-6-16) "For the first time, last year, we had over 110 million interactions between our physicians and our members," said Tyson, adding that 52% of them were done via smartphone, videoconferencing, kiosks, and other technology tools. "What were now seeing is greater interaction with our members and the health care system," said Tyson. "They're asking different questions, they're behaving more like consumers, and medical information now is becoming a critical part of how they're making life choices."
• Charlotte patients take control of their medical records, doctor visits with virtual care (Karen Garloch, Charlotte Observer, 12-20-14) After downloading a new app to her iPhone, within minutes Beth Straeten was talking face-to-face with a physician assistant. As Straeten described the poison ivy rash on her arms, PA Dimple Joshi sat across town at Carolinas Medical Center-Pineville, in front of two computer monitors. On one, Joshi could see Straeten and on the other she could read Straeten’s medical record. This has been called medicine’s “Gutenberg moment” by Dr. Eric Topol, one of the nation’s leading cardiologists. Much like the printing press liberated knowledge from control of the elite class, Topol says digital health technology is poised to democratize medicine in ways that were unimaginable until now. “It goes from being the doctor’s medical record to being the patient’s medical record,” said Dr. R. Henry Capps Jr.
• Telehealth back in the spotlight (Covering Health, Association of Health Care Journalists, 8-7-17) Lack of reimbursement for telehealth has for many years been an impediment to adoption.Three proposed initiatives would remove some longstanding roadblocks to wider adoption of telehealth services. One proposal would eliminate the state-by-state licensure requirement for telehealth delivery for all federal programs, including Medicare (so the patient wouldn't have to be in the same state as the doctor). The proposed Evidence-Based Telehealth Expansion Act of 2017 would waive current Medicare restrictions on telehealth coverage as long as it saves money. The proposed CHRONIC Care Act of 2017 would offer accountable care organizations and Medicare Advantage plans greater flexibility in reimbursement for telehealth services, and eliminate geographic restrictions for telestroke service payments.
• Get Your Checkup by Phone or Video (Beth Howard, The Investing Revolution, US News, 8-26-16) "When 11-month-old Jack Causa's eyes became red and developed a yellow discharge last winter, his mother Izzy immediately recognized the problem: pinkeye. Because the pediatrician's office was closed, she used a service called Teladoc, provided through her health benefits, to reach a physician on her smartphone....Teladoc is one of several services, including MDLIVE, American Well, and Doctor on Demand, offering secure access to a doctor anytime, anywhere to anyone with a smartphone or tablet. "
• Choice, Transparency, Coordination, and Quality Among Direct-to-Consumer Telemedicine Websites and Apps Treating Skin Disease (Jack S. Resneck Jr, MD, et al., JAMA Dermatology, 5-1-13) Telemedicine has potential to expand access to high-value health care. Our findings, however, raise concerns about the quality of skin disease diagnosis and treatment provided by many DTC telemedicine websites. Until improvements are made, patients risk using health care services that lack transparency, choice, thoroughness, diagnostic and therapeutic quality, and care coordination. We offer several suggestions to improve the quality of DTC telemedicine websites and apps and avoid further growth of fragmented, low-quality care.
• Big business backs virtual doctor visits as Texas loses fight for limits (Jayne O'Donnell, USA Today, 6-3-15) Video or telephone visits with doctors — the practice known as telemedicine — have survived one of their biggest legal challenges yet in Texas, but hurdles remain in Arkansas and some other states.
• The FDA Just Opened Up Abortion Pill Access. Next Up: Webcam Prescriptions (Sarah Zhang, Wired, 3-31-16)
• Telemedicine fans point to CBO's history of cost overestimates (David Pittman, Politico, 12-21-15) The Congressional Budget Office's track record with telemedicine isn’t very positive. Advocates need to find better ways to show CBO their proposed changes work and will save money. “They do seek to be fair, but they’re also careful,” Schwartz said.
• Virtual reality: More insurers are embracing telehealth (Bob Herman, Modern Healthcare, 2-20-16)

• Yoga overview (National Center for Complementary and Integrative Health)
• What the Science Says About Yoga "Current research suggests that a carefully adapted set of yoga poses may reduce low-back pain and improve function. Other studies also suggest that practicing yoga (as well as other forms of regular exercise) might improve quality of life; reduce stress; lower heart rate and blood pressure; help relieve anxiety, depression, and insomnia; and improve overall physical fitness, strength, and flexibility. But some research suggests yoga may not improve asthma, and studies looking at yoga and arthritis have had mixed results." From Yoga: In Depth
• Effectiveness of Iyengar yoga in treating spinal (back and neck) pain: A systematic review. (Crow EM, Jeannot E, Trewhela A, Intl J Yoga, on PubMed, Jan. 2015). "This systematic review found strong evidence for short-term effectiveness, but little evidence for long-term effectiveness of yoga for chronic spine pain in the patient-centered outcomes. "
• Health conditions benefited by yoga (Timothy McCall, MD, from Yoga as Medicine ), a list followed by links to many references.
• Western Science vs. Eastern Wisdom (PDF, Timothy McCall). See also Does Yoga Kill? Yoga, Truthiness and the New York Times, in which McCall argues against New York Times writer William Broad's claims that yoga is responsible for hundreds of strokes per year﻿, the emotional linchpin of his yoga-wrecks-your-body arguments. About which, see next entry:
• How Yoga Can Wreck Your Body (William J. Broad, NY Times, 1-5-12) and this follow-up piece: The Healing Power of Yoga Controversy (William Broad, The 6th Floor: Eavesdropping on the Times Magazine, 1-10-13) "Yet, for all the bad news about yoga, I still see the rewards as outweighing the risks. A century and a half of science shows the benefits to be many — and the serious dangers to be few and comparatively rare."